Health Plan Weekly

As states resumed their Medicaid eligibility redeterminations last spring, some experts suggested that states should prioritize enrolling Medicaid managed care (MMC) enrollees who were losing coverage with the same carrier in the Affordable Care Act (ACA) individual marketplace. Private insurers like Centene Corp. have also emphasized this strategy, with the goal of stemming member attrition. However, a new study from Health Affairs suggests that “a within-carrier transition is likely to be possible only for roughly half of Medicaid managed care enrollees.”

By examining Clarivate’s InterStudy enrollment data from 2021, researchers found that in 2021, 52.1% of MMC members were enrolled by a carrier that also had a plan on the ACA marketplace in the same county. Among all MMC enrollees, 24.5% were in counties where the largest insurer was the same in both Medicaid and the ACA marketplace. In 10.3% of the 2,625 counties with MMC, all MMC enrollees were in a plan offered by an insurer that also had a marketplace plan.

Doctors are increasingly turning to artificial intelligence (AI) chatbots to fight back against health insurers’ claim denials and prior authorization requests, The New York Times reported. Tools like ChatGPT and the HIPAA-compliant Doximity GPT are helping justify treatments they say patients need by drafting letters in seconds that cite scientific studies to back up their arguments. One doctor told the publication that Doximity GPT cut the time he spent on prior authorization requests in half. Major insurers, meanwhile, are facing increasing scrutiny — and a spate of lawsuits –— over their use of AI for tasks like denying large batches of claims or determining the length of patients’ post-acute rehabilitation stays. An AHIP spokesperson told the Times that the insurer trade group welcomes efforts to streamline the prior authorization process, including those that involve the “appropriate use” of AI. 

On June 28, the U.S. Supreme Court in two rulings eliminated a longstanding legal precedent that has protected regulations issued by federal agencies from a broad swath of legal challenges. Attorneys say rulemaking in health care will become more unpredictable as regulations are challenged — which could cost health plans, providers, and patients.

In their rulings in Relentless v. Department of Commerce and Loper Bright Enterprises v. Raimondo, the Supreme Court did away with “Chevron deference,” a legal concept that is over 40 years old. Chevron deference granted agencies the legal benefit of the doubt when they issued regulations that clarified parts of statute that Congress had left ambiguous. The premise behind the concept was that agency staff have subject matter expertise that Congress is unlikely to share, and that Congress couldn’t be expected to continually update statutes in order to address every emerging issue of importance to a specific sector of the economy.

A federal appeals court recently ruled that former Cigna Group executive Amy Bricker cannot join rival CVS Health Corp. due to a noncompete agreement, upholding a preliminary injunction from last year. While the case involving Bricker suggests companies can effectively prohibit employees from switching jobs, firms may no longer be able to do so later this year.

A Federal Trade Commission (FTC) final rule published in the Federal Register in May would ban most firms from enforcing or signing noncompetes with their workers. However, two attorneys tell AIS Health, a division of MMIT, the rule may not go into effect as planned on Sept. 4 due to multiple appeals. Indeed, in a July 3 ruling that put the ban on hold for groups seeking to overturn it, a federal judge wrote that the challenge is "likely to succeed on the merits."

While use cases for artificial intelligence are still largely being tested in health care, AI may be helpful right now for health plans seeking to manage their provider directories — a troublesome task that even the largest payers struggle to handle.

“There’s a lot of hype here, and really, so far, not much has really materialized,” said Neel Butala, M.D., cofounder of HiLabs, during a June 25 AHIP webinar.

“However, there’s a big appetite [for AI]…everything ranging from automating administrative tasks, apps, data analytics, to risk prediction, and even you know, personalized medicine. AI has applications in each of these buckets with varying ranges of maturity. And we feel, right now at least, that the easiest thing for people to engage AI in right now is automating administrative tasks. And this is because it improves efficiency; has direct, easily measurable ROI; and it’s pretty low risk for health plans in particular, as it's not really directly involved in member care. And finally, an easy win here can help any AI across an organization that can then be used…for other types of applications that are more advanced, that have a big impact.”