Thompson Coburn accomplice Mackenzie Wallace was the featured visitor on a latest episode of AHLA’s Talking of Well being Regulation Podcast, the place she sat down with Bob Paskowski, Consulting Principal, PYA, to debate the newest tendencies and challenges dealing with the supplier and payer in right this moment’s well being care market. Mackenzie and Bob mentioned a few of the sensible suggestions they provide shoppers who’re making an attempt to navigate the present panorama, OIG’s April 2022 report addressing Medicare Benefit denials of prior authorization requests, the affect of the No Surprises Act’s (NSA) unbiased dispute decision course of and way more.
The episode lays out the numerous challenges within the well being care market on each the supplier facet and the payer facet. On the supplier facet, the pair factors out that the well being methods and doctor teams are dealing with vital headwinds and challenges particularly on their expense facet of the enterprise. Challenges embody labor shortages each on the medical and the executive facet and elevated provide prices. On the payer facet, they are saying points embody making an attempt to maintain prices down and never succumbing to a request for a charge enhance.
Mackenzie stated there are a number of discussions within the business about inflation, the price of well being care and the burden on shoppers. Nonetheless, she stated, “There was not a number of dialogue about this specific situation, which is supplier and payer points and the way it impacts that intersection of price and worth and inflation.” The supplier a d the payer must create options to reduce a few of the issues and reduce the executive burden that additional drives prices up for the entire events concerned.
Mackenzie additionally mentioned the OIG report that was issued in April 2022 that addressed Medicare Benefit denials of prior authorization requests and raised issues about beneficiary entry to medically obligatory care. She stated there are a sure share of claims the place no mistake by the supplier was made, and these claims are nonetheless not being paid correctly as a result of a distinct rubric is being utilized than what’s legally required. Mackenzie stated, “And that’s actually related to the underlying dispute as a result of when that happens, it will increase closely the executive burden for the suppliers to receives a commission. And the top result’s the combat that actually led to the NSA, which is that customers are paying an excessive amount of.”
