Health Plan Weekly

In a rule proposed on Dec. 6, CMS seeks to impose new requirements on federally funded health plans surrounding their prior authorization processes and data interoperability. While that might normally induce private payers to push back, the health insurance sector’s main trade group has already endorsed the regulation, which CMS issued to replace a previously proposed rule that appears to have generated more industry pushback. Health care industry observers, meanwhile, tell AIS Health that the new requirements could be a win for consumers, providers, and payers alike. 

“I think it’s good for the business,” says Katherine Hempstead, Ph.D., a senior policy adviser at the Robert Wood Johnson Foundation. “It’s good immediately for consumers and providers, and it’s good in the long run for plans. It’s going to be better for everyone.” 

The pandemic-induced telehealth revolution expanded access to an exciting new modality of care delivery, but a new report from federal watchdogs found that federal payers face new, telehealth-derived challenges in stopping waste, fraud and abuse. Those findings mean the commercial carriers that administer certain federally underwritten health insurance plans have a new auditing and accountability challenge as telehealth settles in as a permanent part of the care delivery landscape. 

The report, prepared by six Offices of Inspectors General (OIGs) from HHS, the Dept. of Justice, Dept. of Defense, Dept. of Veterans Affairs (VA), Dept. of Labor and Office of Personnel Management (OPM), found that “while the expansion of telehealth has been essential to maintaining individuals’ access to care, there have been concerns about the potential for fraud, waste, and abuse associated with expanded telehealth services.”  

As health insurers rapidly expand their technology divisions and ally with tech companies to create population health and business insights, many health care leaders have expressed a hope that new technologies and insights can help tackle social determinants of health (SDOH). Those tools hold great promise, according to experts, but must be paired with old-school, community-based coalition building to be successful. 

During a panel convened for a Dec. 6 Milliman Inc. webinar, health tech experts from organizations including Independence Blue Cross and Microsoft Corp. agreed that population health and equity insights can’t move the needle on SDOH if they aren’t paired with grassroots coalitions.