5 ms·

It ought to be the law that approved claims should be backdated to when the initial claim was made. UHC pulled this exact trick on me, denying something that ou

It ought to be the law that approved claims should be backdated to when the initial claim was made. UHC pulled this exact trick on me, denying something that ought to have been approved in order to push the date into the new plan year with a reset deductible.

mindslight 2y ago
It ought to be the law that every in-network claim must be automatically approved. In network providers have already jumped through hoops to have that contract with the "insurance" company, including the creation of documentation to satisfy the "insurance" company of their judgement. It's disingenuous for an "insurance" company to then claim to be second guessing the very professionals' judgement they've already examined and approved of.
- tptacek 2y ago
  Ro Khanna said something similar a week or so ago. You all get that this would basically be the biggest corporate giveaway in the history of American politics, right? The reason you're getting health care denials is that providers are trying to rip your face off. I'm pleading with people on this site to go look at where the dollars in health care spending actually go. CMS, the government organization that manages Medicare (and somehow got vilified a few weeks ago when Blue Cross tried to adopt Medicare's anesthesia billing rules), tracks this stuff in a set of documents called the National Health Expenditures. They're spreadsheets, they're easy to go read, please, for the love of all that is holy, go look at them before designing policy.
  - alistairSH 2y ago
    I can see where the money goes. That doesn’t absolve the insurance industry of being a festering sore worthy of every bit of scorn sent their direction.
  - inferiorhuman 2y ago
    and somehow got vilified a few weeks ago when Blue Cross tried to adopt Medicare's anesthesia billing rules LOL That is absolutely fucking NOT why Blue Cross Blue Shield got vilified. Please stop making disingenuous arguments. BCBS attempted to weaponize Medicare statistics and set a hard cap on anesthesia coverage based on the average time Medicare says a procedure takes. This is NOT how Medicare reimbursement works. Medicare pays anesthesia providers for the entire time a patient is under. Full stop.
    - tptacek 2y ago
      No, from everything I understand about the situation, this is the opposite of the truth. Feel free to cite a source saying otherwise! I'll read it!
      - inferiorhuman 2y ago
        Yeah, go read the rules set forth by CMS. Medicare pays for the entire cost of anesthesia. So here's why I'm so dismissive of your garbage argument. From Medicare's policy manual: https://www.cms.gov/files/document/chapter2cptcodes00000-01999final11.pdf https://www.cms.gov/files/document/chapter2cptcodes00000-019... A unique characteristic of anesthesia coding is the reporting of time units. Payment for anesthesia services increases with time. In addition to reporting a base unit value for an anesthesia service, the anesthesia practitioner reports anesthesia time. Anesthesia time is defined as the period during which an anesthesia practitioner is present with the patient. It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient (i.e., when the patient may be placed safely under postoperative care). Compare this to BCBS's policy (which they've tried to scrub from the internet): https://www.asahq.org/about-asa/newsroom/news-releases/2024/11/anthem-blue-cross-blue-shield-will-not-pay-complete-duration-of-anesthesia-for-surgical-procedures https://www.asahq.org/about-asa/newsroom/news-releases/2024/... Anthem will arbitrarily pre-determine the time allowed for anesthesia care during a surgery or procedure. If an anesthesiologist submits a bill where the actual time of care is longer than Anthem's limit, Anthem will deny payment for the anesthesiologist’s care. With this new policy, Anthem will not pay anesthesiologists for delivering safe and effective anesthesia care to patients who may need extra attention because their surgery is difficult, unusual or because a complication arises. There's a vast gulf between those two approaches. Medicare pays for the time a procedure takes, BCBS does not. BCBS deserves every ounce of vitriol they got over that. Your entire argument appears to be that doctors are corrupt and cannot be trusted which is entirely orthogonal to the the issue with pre-determining the amount of time a procedure will take. Meanwhile BCBS overcharged (a.k.a. fraudulently charged) the federal government for over $100 million. Doctors are not the problem with health care in the United States. https://www.reuters.com/legal/anthem-must-face-us-government-lawsuit-alleging-medicare-advantage-fraud-2022-10-03/ https://www.reuters.com/legal/anthem-must-face-us-government... UHC? $7.5 billion (with a b) in fraudulent Medicare charges. https://www.startribune.com/report-unitedhealth-group-tops-list-of-medicare-advantage-insurers-receiving-billions-in-questionable-payments/601169613 https://www.startribune.com/report-unitedhealth-group-tops-l... Cigna? They settled their fraud cases for $200+ million. https://www.justice.gov/opa/pr/cigna-group-pay-172-million-resolve-false-claims-act-allegations https://www.justice.gov/opa/pr/cigna-group-pay-172-million-r... https://www.justice.gov/usao-sdny/pr/united-states-reaches-37-million-settlement-fraud-lawsuit-against-cigna-submitting https://www.justice.gov/usao-sdny/pr/united-states-reaches-3... Independent Health Association? $100 million. https://kffhealthnews.org/news/article/medicare-advantage-fraud-lawsuit-settlement-new-york/ https://kffhealthnews.org/news/article/medicare-advantage-fr... Private insurance is one of the biggest drivers of the obscene cost of health care in this country.
  - mindslight 2y ago
    I've read similar comments of yours in other threads, and have thought them on point. I certainly don't see "insurance" companies as the single source of bad of the whole system. Personally, I just got done dealing with an 11 month billing headache spearheaded by entitled "providers" double billing, and shamelessly telling me that they don't have the resources to follow up on claims I told them needed to be followed up on, while still continuing to send me fraudulent bills with fake amounts and fake due dates. Meanwhile, despite their "bucket of stomach fluid" bureaucracy, the "insurance" company straightforwardly communicated what I should (not) be responsible for (at least until the rep I was emailing back and forth ghosted me because he got memory-holed). Heck I'm not even really a proponent of single payer versus reforming the industry so it has to abide by the common sense norms of commerce like every other industry. So the "you all" grouping falls a little flat here. But read what I wrote again - the point is that every "in network" provider of an HMO is already accountable to the HMO while providing care to their members. If an HMO wants to limit certain types of care, then that needs to be expressed to providers (through their contracts), who can immediately tell patients "As a doctor I would recommend you get this type of treatment, but while working for $HMO I cannot provide it as your plan doesn't cover it". My initial comment was phrased in terms of insurance companies, but this double approval blame game is actually more a problem with the entitlement of doctors never wanting to deal with the reality of what services cost.
  - unethical_ban 2y ago
    I know you're getting at a specific point. And I'm aware that health insurers are not the only moneymaking component in the health care pipeline. I don't think eliminating profit is doable. Capitalism is the worst system other than all the rest. But surely we can agree that health insurers that are publicly traded do not prioritize human outcomes. The profit motive needs to be tempered, if not entirely removed, from health insurance. Profit motive should be tempered in the basic healthcare space. Excessive testing and treatment are a thing too, I understand. What I guess I'm saying is, I know it's complicated, but no amount of nuance absolves UHC and others for the kinds of denial stories that people have been telling. (I don't work Monday... I may be rambling).
    - tptacek 2y ago
      They're not just "not the only" moneymaking component; they're an order of magnitude and another integer factor away from being one of the most significant. The problem in American health care is (1) how much providers charge and (2) how many procedures and services are prescribed.
    - ruthmarx 2y ago
      > Capitalism is the worst system other than all the rest. This isn't anything to do with capitalism. It's all to do with Republicans bizarre obsession with 'small government'. These kind of healthcare horrors don't happen in most western countries, because they have reasonable regulations and socialized healthcare in place.
      - tptacek 2y ago
        Well, that, and they pay their doctors 3-5x less.
  - mw1 2y ago
    One reason you may need to continually plead with people about this is because so many of us have had lived experiences with valid medical claims that should be covered under our policy, denied outright. Not a health insurance company saying “oh, that’s too expensive, go here for less,” but outright denial of coverage. And if we eventually succeed in having these claims covered, it is because we were willing to spend countless hours combing through paperwork, initial delays, and denials. Also, the same CMS statistics you cite can be combined with other reports to conclude that 500 billion dollars of excess administrative costs PER YEAR are attributable to our lack of a single payer system — something UHC has lobbied heavily against in order to protect their profits over the improved health care of the average American. You can read the numbers here: https://www.peoplespolicyproject.org/2024/12/10/health-care-administration-wastes-half-a-trillion-dollars-every-year/ https://www.peoplespolicyproject.org/2024/12/10/health-care-... “private insurers currently have administrative costs that are 1,000 percent what they would be under single-payer while hospitals currently have administrative costs that are 158 percent what they would be under single-payer. The excess administrative expenses of both the payers and the providers are because of the multi-payer private health insurance system that we have. When you add it all up, excess administrative expenses — defined as administrative expenses we have under the current system that we would not have under single-payer — are equal to 1.8 percent of GDP, or $528 billion per year.” Another reason your pleading falls on deaf ears is that, sure, provider payments can be reduced (and this addressed in the above article), but at the end of the day, private insurance is a purely rent-seeking enterprise that provides no value to Americans while these “overpaid providers” are actually delivering the care.
    - tptacek 2y ago
      2.21 trillion dollars per year of provider costs, against 279 billion dollars net cost of health insurance. But yeah, the one player in this market that has its profits capped statutorily, they're they're the whole problem, no matter what the numbers say. Sure. I'm not telling you there's no problem. I'm saying that you've been conned into believing the problem is something it isn't.
      - mw1 2y ago
- _yb2s 2y ago
  That is how Kaiser works- the doctors have internal guidelines, e.g. a set criteria for a diagnosis, and every treatment that is ordered is automatically approved. This isn't a perfect solution either though- the guidelines are often unreasonably strict, and still deny people treatments they very much need.
  - tptacek 2y ago
    The difference being that in the Kaiser system, the doctors work for Kaiser, and not for health provider chains.
- JumpCrisscross 2y ago
  > ought to be the law that every in-network claim must be automatically approved This almost certainly requires vertical integration between providers and insurers. That or shifting approval/denial to the provider level, i.e. your doctor can fall off the approval list from month to month for submitting too many claims. If not, providers will become the most profitable business on the planet right until every health insurer goes bankrupt. (We’ll probably get to blame it on PE-run hospitals, even if everyone is doing it.)
  - ocschwar 2y ago
    Providers are liable for malpractice if they approve un-needed treatments, and all drugs have side effects. And they meanwhile have their own liability insurance to pay, as well as medical student debt. So not going to be profitable either. Unless they start prescribing Carnival Cruise therapy or stiff like that.
    - JumpCrisscross 2y ago
      > Providers are liable for malpractice if they approve un-needed treatments There is a lot of grey area between necessary to the point of malpractice if not provided and unnecessary to the point of malpractice. Like, you’re not going to win a malpractice case because your doctor prescribed too many non-invasive tests and MRIs. And if my insurer is forced to approve every MRI, I'm probably going to ask my doctor for an MRI.
    - nradov 2y ago
      It is simply naive to think that the threat of malpractice discipline by state medical boards would deter bad actors from delivering wasteful or unnecessary care. The fee-for-service financial system heavily incentivizes over treatment. If you don't believe me then read "The Price We Pay" by Dr. Marty Makary. It documents many such incidents for which the providers were never punished. https://www.bloomsbury.com/us/price-we-pay-9781635575910/ https://www.bloomsbury.com/us/price-we-pay-9781635575910/
  - xbar 2y ago
    I mean, it was fine for 50 years.
- rjbwork 2y ago
  For providers with a history of high quality PA requests and high approval rates, there is something similar. See https://www.uhc.com/news-articles/newsroom/gold-card https://www.uhc.com/news-articles/newsroom/gold-card Other insurers have similar programs.
  - mindslight 2y ago
    Sounds like another layer of "gotchas" to pin more work and blame on patients, while still not providing any guarantee. "Your healthcare was denied because while you may have checked the provider was 'in network', you did not also check to see if they have earned a gold star. I can email you a list of our highest quality providers that have earned gold stars"... Then most aren't taking new patients, and the one or two that do are booking out the better part of a year for a new patient visit. I'll go out on a limb and say that the proliferation of these punt-the-problem administrative layers (in lieu of straightforwardly owning and solving problems) is one of the main things driving the medical industry's cost disease. A few years from now this "gold card" program will likely be administered by a newly spun out "third party" vendor that doesn't publish updated lists very well, but if you feel you were treated unfairly you can always file an appeal with them...
nradov 2y ago
In terms of annual deductible, claims are always dated to the date of service regardless of when they were submitted or adjudicated. I think what you're asking for is that if a prior authorization request is submitted in one plan year then all claims linked to that request should be counted towards the deductible in that plan year regardless of the date of service. That might help some plan members but would hurt others depending on timing. Health plans covered by the CMS-0057-F final rule are generally required to issue decisions on prior auth requests within 7 days. But that rule doesn't apply to most private commercial health plans. https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f https://www.cms.gov/newsroom/fact-sheets/cms-interoperabilit...

mindslight 2y ago

It ought to be the law that every in-network claim must be automatically approved. In network providers have already jumped through hoops to have that contract with the "insurance" company, including the creation of documentation to satisfy the "insurance" company of their judgement. It's disingenuous for an "insurance" company to then claim to be second guessing the very professionals' judgement they've already examined and approved of.

tptacek 2y ago
Ro Khanna said something similar a week or so ago. You all get that this would basically be the biggest corporate giveaway in the history of American politics, right? The reason you're getting health care denials is that providers are trying to rip your face off. I'm pleading with people on this site to go look at where the dollars in health care spending actually go. CMS, the government organization that manages Medicare (and somehow got vilified a few weeks ago when Blue Cross tried to adopt Medicare's anesthesia billing rules), tracks this stuff in a set of documents called the National Health Expenditures. They're spreadsheets, they're easy to go read, please, for the love of all that is holy, go look at them before designing policy.
- alistairSH 2y ago
  I can see where the money goes. That doesn’t absolve the insurance industry of being a festering sore worthy of every bit of scorn sent their direction.
- inferiorhuman 2y ago
  and somehow got vilified a few weeks ago when Blue Cross tried to adopt Medicare's anesthesia billing rules LOL That is absolutely fucking NOT why Blue Cross Blue Shield got vilified. Please stop making disingenuous arguments. BCBS attempted to weaponize Medicare statistics and set a hard cap on anesthesia coverage based on the average time Medicare says a procedure takes. This is NOT how Medicare reimbursement works. Medicare pays anesthesia providers for the entire time a patient is under. Full stop.
  - tptacek 2y ago
    No, from everything I understand about the situation, this is the opposite of the truth. Feel free to cite a source saying otherwise! I'll read it!
    - inferiorhuman 2y ago
      Yeah, go read the rules set forth by CMS. Medicare pays for the entire cost of anesthesia. So here's why I'm so dismissive of your garbage argument. From Medicare's policy manual: https://www.cms.gov/files/document/chapter2cptcodes00000-01999final11.pdf https://www.cms.gov/files/document/chapter2cptcodes00000-019... A unique characteristic of anesthesia coding is the reporting of time units. Payment for anesthesia services increases with time. In addition to reporting a base unit value for an anesthesia service, the anesthesia practitioner reports anesthesia time. Anesthesia time is defined as the period during which an anesthesia practitioner is present with the patient. It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient (i.e., when the patient may be placed safely under postoperative care). Compare this to BCBS's policy (which they've tried to scrub from the internet): https://www.asahq.org/about-asa/newsroom/news-releases/2024/11/anthem-blue-cross-blue-shield-will-not-pay-complete-duration-of-anesthesia-for-surgical-procedures https://www.asahq.org/about-asa/newsroom/news-releases/2024/... Anthem will arbitrarily pre-determine the time allowed for anesthesia care during a surgery or procedure. If an anesthesiologist submits a bill where the actual time of care is longer than Anthem's limit, Anthem will deny payment for the anesthesiologist’s care. With this new policy, Anthem will not pay anesthesiologists for delivering safe and effective anesthesia care to patients who may need extra attention because their surgery is difficult, unusual or because a complication arises. There's a vast gulf between those two approaches. Medicare pays for the time a procedure takes, BCBS does not. BCBS deserves every ounce of vitriol they got over that. Your entire argument appears to be that doctors are corrupt and cannot be trusted which is entirely orthogonal to the the issue with pre-determining the amount of time a procedure will take. Meanwhile BCBS overcharged (a.k.a. fraudulently charged) the federal government for over $100 million. Doctors are not the problem with health care in the United States. https://www.reuters.com/legal/anthem-must-face-us-government-lawsuit-alleging-medicare-advantage-fraud-2022-10-03/ https://www.reuters.com/legal/anthem-must-face-us-government... UHC? $7.5 billion (with a b) in fraudulent Medicare charges. https://www.startribune.com/report-unitedhealth-group-tops-list-of-medicare-advantage-insurers-receiving-billions-in-questionable-payments/601169613 https://www.startribune.com/report-unitedhealth-group-tops-l... Cigna? They settled their fraud cases for $200+ million. https://www.justice.gov/opa/pr/cigna-group-pay-172-million-resolve-false-claims-act-allegations https://www.justice.gov/opa/pr/cigna-group-pay-172-million-r... https://www.justice.gov/usao-sdny/pr/united-states-reaches-37-million-settlement-fraud-lawsuit-against-cigna-submitting https://www.justice.gov/usao-sdny/pr/united-states-reaches-3... Independent Health Association? $100 million. https://kffhealthnews.org/news/article/medicare-advantage-fraud-lawsuit-settlement-new-york/ https://kffhealthnews.org/news/article/medicare-advantage-fr... Private insurance is one of the biggest drivers of the obscene cost of health care in this country.
- mindslight 2y ago
  I've read similar comments of yours in other threads, and have thought them on point. I certainly don't see "insurance" companies as the single source of bad of the whole system. Personally, I just got done dealing with an 11 month billing headache spearheaded by entitled "providers" double billing, and shamelessly telling me that they don't have the resources to follow up on claims I told them needed to be followed up on, while still continuing to send me fraudulent bills with fake amounts and fake due dates. Meanwhile, despite their "bucket of stomach fluid" bureaucracy, the "insurance" company straightforwardly communicated what I should (not) be responsible for (at least until the rep I was emailing back and forth ghosted me because he got memory-holed). Heck I'm not even really a proponent of single payer versus reforming the industry so it has to abide by the common sense norms of commerce like every other industry. So the "you all" grouping falls a little flat here. But read what I wrote again - the point is that every "in network" provider of an HMO is already accountable to the HMO while providing care to their members. If an HMO wants to limit certain types of care, then that needs to be expressed to providers (through their contracts), who can immediately tell patients "As a doctor I would recommend you get this type of treatment, but while working for $HMO I cannot provide it as your plan doesn't cover it". My initial comment was phrased in terms of insurance companies, but this double approval blame game is actually more a problem with the entitlement of doctors never wanting to deal with the reality of what services cost.
- unethical_ban 2y ago
  I know you're getting at a specific point. And I'm aware that health insurers are not the only moneymaking component in the health care pipeline. I don't think eliminating profit is doable. Capitalism is the worst system other than all the rest. But surely we can agree that health insurers that are publicly traded do not prioritize human outcomes. The profit motive needs to be tempered, if not entirely removed, from health insurance. Profit motive should be tempered in the basic healthcare space. Excessive testing and treatment are a thing too, I understand. What I guess I'm saying is, I know it's complicated, but no amount of nuance absolves UHC and others for the kinds of denial stories that people have been telling. (I don't work Monday... I may be rambling).
  - tptacek 2y ago
    They're not just "not the only" moneymaking component; they're an order of magnitude and another integer factor away from being one of the most significant. The problem in American health care is (1) how much providers charge and (2) how many procedures and services are prescribed.
  - ruthmarx 2y ago
    > Capitalism is the worst system other than all the rest. This isn't anything to do with capitalism. It's all to do with Republicans bizarre obsession with 'small government'. These kind of healthcare horrors don't happen in most western countries, because they have reasonable regulations and socialized healthcare in place.
    - tptacek 2y ago
      Well, that, and they pay their doctors 3-5x less.
- mw1 2y ago
  One reason you may need to continually plead with people about this is because so many of us have had lived experiences with valid medical claims that should be covered under our policy, denied outright. Not a health insurance company saying “oh, that’s too expensive, go here for less,” but outright denial of coverage. And if we eventually succeed in having these claims covered, it is because we were willing to spend countless hours combing through paperwork, initial delays, and denials. Also, the same CMS statistics you cite can be combined with other reports to conclude that 500 billion dollars of excess administrative costs PER YEAR are attributable to our lack of a single payer system — something UHC has lobbied heavily against in order to protect their profits over the improved health care of the average American. You can read the numbers here: https://www.peoplespolicyproject.org/2024/12/10/health-care-administration-wastes-half-a-trillion-dollars-every-year/ https://www.peoplespolicyproject.org/2024/12/10/health-care-... “private insurers currently have administrative costs that are 1,000 percent what they would be under single-payer while hospitals currently have administrative costs that are 158 percent what they would be under single-payer. The excess administrative expenses of both the payers and the providers are because of the multi-payer private health insurance system that we have. When you add it all up, excess administrative expenses — defined as administrative expenses we have under the current system that we would not have under single-payer — are equal to 1.8 percent of GDP, or $528 billion per year.” Another reason your pleading falls on deaf ears is that, sure, provider payments can be reduced (and this addressed in the above article), but at the end of the day, private insurance is a purely rent-seeking enterprise that provides no value to Americans while these “overpaid providers” are actually delivering the care.
  - tptacek 2y ago
    2.21 trillion dollars per year of provider costs, against 279 billion dollars net cost of health insurance. But yeah, the one player in this market that has its profits capped statutorily, they're they're the whole problem, no matter what the numbers say. Sure. I'm not telling you there's no problem. I'm saying that you've been conned into believing the problem is something it isn't.
    - mw1 2y ago
_yb2s 2y ago
That is how Kaiser works- the doctors have internal guidelines, e.g. a set criteria for a diagnosis, and every treatment that is ordered is automatically approved. This isn't a perfect solution either though- the guidelines are often unreasonably strict, and still deny people treatments they very much need.
- tptacek 2y ago
  The difference being that in the Kaiser system, the doctors work for Kaiser, and not for health provider chains.
JumpCrisscross 2y ago
> ought to be the law that every in-network claim must be automatically approved This almost certainly requires vertical integration between providers and insurers. That or shifting approval/denial to the provider level, i.e. your doctor can fall off the approval list from month to month for submitting too many claims. If not, providers will become the most profitable business on the planet right until every health insurer goes bankrupt. (We’ll probably get to blame it on PE-run hospitals, even if everyone is doing it.)
- ocschwar 2y ago
  Providers are liable for malpractice if they approve un-needed treatments, and all drugs have side effects. And they meanwhile have their own liability insurance to pay, as well as medical student debt. So not going to be profitable either. Unless they start prescribing Carnival Cruise therapy or stiff like that.
  - JumpCrisscross 2y ago
    > Providers are liable for malpractice if they approve un-needed treatments There is a lot of grey area between necessary to the point of malpractice if not provided and unnecessary to the point of malpractice. Like, you’re not going to win a malpractice case because your doctor prescribed too many non-invasive tests and MRIs. And if my insurer is forced to approve every MRI, I'm probably going to ask my doctor for an MRI.
  - nradov 2y ago
    It is simply naive to think that the threat of malpractice discipline by state medical boards would deter bad actors from delivering wasteful or unnecessary care. The fee-for-service financial system heavily incentivizes over treatment. If you don't believe me then read "The Price We Pay" by Dr. Marty Makary. It documents many such incidents for which the providers were never punished. https://www.bloomsbury.com/us/price-we-pay-9781635575910/ https://www.bloomsbury.com/us/price-we-pay-9781635575910/
- xbar 2y ago
  I mean, it was fine for 50 years.
rjbwork 2y ago
For providers with a history of high quality PA requests and high approval rates, there is something similar. See https://www.uhc.com/news-articles/newsroom/gold-card https://www.uhc.com/news-articles/newsroom/gold-card Other insurers have similar programs.
- mindslight 2y ago
  Sounds like another layer of "gotchas" to pin more work and blame on patients, while still not providing any guarantee. "Your healthcare was denied because while you may have checked the provider was 'in network', you did not also check to see if they have earned a gold star. I can email you a list of our highest quality providers that have earned gold stars"... Then most aren't taking new patients, and the one or two that do are booking out the better part of a year for a new patient visit. I'll go out on a limb and say that the proliferation of these punt-the-problem administrative layers (in lieu of straightforwardly owning and solving problems) is one of the main things driving the medical industry's cost disease. A few years from now this "gold card" program will likely be administered by a newly spun out "third party" vendor that doesn't publish updated lists very well, but if you feel you were treated unfairly you can always file an appeal with them...

nradov 2y ago

In terms of annual deductible, claims are always dated to the date of service regardless of when they were submitted or adjudicated. I think what you're asking for is that if a prior authorization request is submitted in one plan year then all claims linked to that request should be counted towards the deductible in that plan year regardless of the date of service. That might help some plan members but would hurt others depending on timing. Health plans covered by the CMS-0057-F final rule are generally required to issue decisions on prior auth requests within 7 days. But that rule doesn't apply to most private commercial health plans. https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f https://www.cms.gov/newsroom/fact-sheets/cms-interoperabilit...