Jeff Evans, CRM, ACSF Passionate Risk/Insurance Educator-Coach-Author

Understanding Utilization Management in Medical Insurance   Utilization management is a continuous process aimed at ensuring that medical decisions & services are eligible under the insured's current plan, confirming that these decisions & services are the best option for the patient, maximizing insurance benefits to the insured by providing the best service at the lowest cost, & applying quality standards consistently.   The importance of utilization management cannot be overstated. For the country, it helps to avoid the waste of the already-limited national resources. For insurers, it prevents unfair profit losses & protects their reputation. For the insured, it ensures better health outcomes, prevents the waste of insurance benefits, & avoids higher premiums.   Utilization management can be prospective, concurrent, & retrospective. Prospective management occurs before service provision & includes demand management, referral management, & prior authorization. Concurrent management happens during service provision & involves prior authorization, field reviews, & case management. Retrospective management takes place after service provision & includes claims processing & trend analysis.   However, the implementation of utilization management comes with its own set of challenges. One is the administrative burden it places on healthcare providers & insurers, requiring meticulous documentation & communication. Second, there can be resistance from providers who may perceive these measures as hindering their autonomy & negatively impacting their revenues. Patients might also find the process cumbersome, potentially leading to delays in receiving care. Ensuring the accuracy & consistency of utilization review decisions across different cases is another hurdle. Moreover, maintaining up-to-date knowledge of constantly evolving medical guidelines & insurance policies is essential yet challenging for those involved in utilization management.   To overcome these challenges, several strategies can be employed. Streamlining administrative processes through the use of technology can reduce the burden on healthcare providers & insurers. Training & educating providers on the benefits of utilization management & involving them in the development of policies can help mitigate resistance. Clear & effective communication with clients about the process can alleviate confusion & reduce delays in care. Establishing standardized protocols & guidelines for utilization review can enhance the accuracy & consistency of decisions. Additionally, ongoing education & training for all stakeholders involved in utilization management are crucial to keep up with evolving medical guidelines & insurance policies.   Despite these challenges, utilization management remains crucial in ensuring that both the insurer & the insured get the best value, maintaining quality & efficiency in medical insurance services.   #MedicalInsurance #HealthcareManagement #HealthcareQuality  

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Once again the media - even senior care specific media - grossly misrepresents and fails to provide valuable context regarding LTC insurance. This news story about a new KFF (Kaiser Family Foundation) report on senior care suggests LTCI is inadequate because out of 7.1-million in-force policies, only 80,000 people filed claims in 2021. Um, this is how insurance is supposed to work! And when looking at long-tail, reserved-based coverage like LTCI, you can't fairly compare total policies with single-year claims data. The author and editors at McKnight's Long-Term Care News fundamentally do not understand insurance ... nor, it's obvious, do they even care to. This is journalistic malpractice. The original KFF report - linked here: https://lnkd.in/exGpAKqP - does, parenthetically, give a bit more context by noting that LTCI has paid claims on a total of 1.5-million people in total ... but the KFF report also misleadingly then provides a graphic bar chart that visually shows 7.1-million in-force policies vs. 80,000 single-year claims (see image in comments below). It SHOULD have shown 7.1-million in-force policies against the 1.5-million total paid claims! And then project LTCI claims of 80,000/year for the next 20 years and we'll have ANOTHER 1.6-million LTCI claims paid! That seems just about right. This is nothing more than a gross manipulation (and misrepresentation) of data in support of a specific agenda (demonizing private insurance to advocate for full public financing & coverage for any/all LTC services for anyone/everyone - which is simply not possible). I can, kinda, forgive KFF for their policy advocacy, because that's what they do (even as they pretend to be "independent"). I can't forgive McKnights for failing to provide its readers with better context and information about LTC insurance. The problem with "studies" and articles like this is it adds to a continuing false narrative about the value and efficacy of LTC insurance that then gets re-quoted as "fact" by other mainstream news sources which perpetuates the misunderstanding among consumers and many financial advisors. #longtermcare #LTCclaims #planning #ComfortLTC

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Understanding the Current Changes in Texas Health Coverage Recent developments in Texas are impacting health insurance coverage and access to care for many residents. Ongoing disputes between major health systems and insurers, shifts in Medicaid contracts, and potential hospital closures are contributing to uncertainty about healthcare options. For those seeking more details on these issues, this article provides an overview of the current situation: https://lnkd.in/g9WHQWrZ At Community Health Choice, we're here to help you navigate these changes. If you have any questions or need assistance, don't hesitate to reach out to us. #HealthCoverage #TexasHealthcare #CommunityHealth

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Group plan administrators: make sure to check this out. The most commonly missed one I see is the minimum deductible threshold to be HSA eligible (when you have a embedded deductible).

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Executive summary notes below ⬇ : ⚖ Health Benefits and Risks: GLP-1 drugs can significantly reduce obesity-related health risks such as diabetes, heart disease, and stroke. However, there is potential misinformation regarding their use, and off-label usage can lead to known and unknown health risks. ❔ FDA Guidelines and Eligibility: Ensuring GLP-1 usage adheres to FDA guidelines is crucial. These drugs should be prescribed based on specific criteria, such as a BMI of 30 or greater (side note that this is an inaccurate measure of obesity but somehow still the standard of care), or 27 with certain co-morbidities. Prior authorization programs can help ensure that only eligible employees receive these medications. 💲 💰 Cost and Financial Considerations: GLP-1 medications are expensive, costing around $1,000 per month without insurance. Despite the initial cost, effective use of these drugs can lead to long-term savings by reducing overall healthcare expenses related to obesity, if used in combination with lifestyle changes. 😎 Employee Satisfaction and Retention: Including GLP-1 coverage in health plans can enhance employee satisfaction and retention. Studies show that companies providing these benefits have higher employee satisfaction, with nearly all employers continuing coverage to show commitment to employee wellbeing. 🧐 🔎 Comprehensive Support Approach: A holistic approach involving due diligence, continuous monitoring, and educational support is essential. Employers can leverage third-party vendors or pharmacy benefit managers to ensure proper use and support for employees, including lifestyle and wellness programs to maintain weight loss after discontinuing GLP-1 drugs. ⚠ Warning from my own research if you are seriously considering adding this benefit: - Patients who fail to adopt and implement complimentary lifestyle changes (eating enough protein and exercising to maintain muscle mass) are likely to regain all of the weight they lost and likely more because they are likely to lose muscle mass, a key factor in burning calories, as a result of GLP-1s utilization. - Offering this benefit could increase your desirability as a destination employer, but it also could attract employees who specifically intend to leverage this benefit, negatively impacting your healthcare costs through adverse selection. #EmployeeBenefits #Wellness #EmployeeSatisfaction #EmployeeRetention

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GLP-1 drugs like #Wegovy cost $17K a year, totaling $274K in a patient's lifetime. Hear how employers and health plan sponsors are managing these costs https://ow.ly/cPwu50SyUJU #EmployeeBenefits #healthcare #pharmacy #GLP1 #WTWPerspective

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Since when did health insurance companies received thier “MD’s”? This is a long article but a fascinating read. We wonder why healthcare costs continue to escalate and premiums are unaffordable? Well, when you have insurance companies being able to add diagnosis’s and conditions to a members healthcare record which allows them to receive more money for treatment - oh and by the way these members don’t have these illnesses…rocket science not needed here! While this seems like its a “Medicare” problem - it’s happening everywhere. In your commercial and group health plan too. Providers trying to charge patients for negotiated discounts, millions of dollars in fake billings, pharmacy rebates being used to increase insurance company profits versus going back to the companies footing these bills or the patients using the drugs. Insurance companies and the organizations that own physician groups and hospitals have figured out how to game the system to increase profits - not deliver better health outcomes. I do believe that there are a lot of great professionals in the medical field that honestly want to improve the lives of people that they treat - they unfortunately now mostly work for companies that don’t really care much about that.

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Could better health pricing transparency be on the way? Find out in the post below from #SempleSolutionsLLC!

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To maximize the affordability and value of GLP-1 treatments, employers should consider a variety of approaches https://ow.ly/Z1s730sGHnQ #EmployeeBenefits #healthcare #Rx #GLP1 #WTWPerspective

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The transition from Fee-For-Service to value-based care in healthcare is essential. This article emphasizes the importance of focusing on quality outcomes over process measures to establish meaningful value-based care more effectively and on a larger scale. #Healthcare #ValueBasedCare #QualityOutcomes

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🌟 Exploring Medicare Part C: The Advantage of All-in-One Coverage 🌟 Navigating the Medicare maze? Let's shine a light on Medicare Part C, also known as Medicare Advantage, and see how it can be a game-changer in your healthcare journey.

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CMS' audit uncovered errors in Aetna's calculation of qualified payment rates for out-of-network emergency services under the No Surprises Act. Aetna based the amounts on claims paid instead of contracted rates, prompting CMS to instruct a self-audit for refunding members if necessary. Additionally, Aetna failed to provide proper notice to providers for dispute resolution, raising concerns about compliance with the law. The American Hospital Association urges increased oversight, highlighting the need for thorough payer audits, adding it is "deeply concerning that the departments have not completed a single audit of payers when the law has been in effect for nearly two full years." #BUCASENSE #Healthcare #Compliance #NoSurprisesAct #Audit #claimsintegrity #overpayments

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I predict that CMS will delay the implementation of the new Medicare regulations for one year, to be announced in the next 5 weeks. No, I do not have any insider information, this is just a prediction based on what I know of policy decision making and the political reality. Right now, there is a multi-level ticking time bomb for seniors that will be going off right before the election. We have a decent amount of MAPD plans being cancelled, many MAPD plans to have much higher premiums, carriers cutting commission on MAPD to reduce their volume, all of which means there will be an immense amount of frustrated seniors who need help from educated agents right when they will not have time nor the economic incentive to spend the time here. We have the effects of the lower than requested reimbursement rates combined with money losing MLR's that have caused carriers to pull back on benefits, increase pricing and terminate a bunch of plans to achieve profitability. The volume of ANOC letters coming to seniors in September will be incredibly high and with much more disruption than we have ever seen. Meanwhile, you have still ambiguous overrides, admin and marketing payments and carriers have not given anyone clarity on the final dollars to be received, so scaled distributors have a very hard time expanding hiring in advance of the biggest shopping year in a decade. Add to that multiple lawsuits that will tie up some CMS resources when they least have them available and for which a loss would be embarrassing and politically problematic. This is a real political problem that is going to heat up a lot of seniors right before an election. I don't see how they fix the MAPD issues, but they can relieve a lot of the pressure if they delay enforcement or decide to pull the rest of the new regs. I am guessing they are reviewing right now and wondering if they can split the baby and keep some of the new regs and delay others or if they have to delay the full enchilada. What do you think?

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To maximize the affordability and value of GLP-1 treatments, employers should consider a variety of approaches https://ow.ly/xMcR30sF3CI #EmployeeBenefits #healthcare #Rx #GLP1 #WTWPerspective

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