Providers push back on insurance cost-cutting hurdles

Editor's Note

Escalating administrative hurdles from insurers are heightening tensions between healthcare payers and providers who criticize the measures for threatening patient care, Modern Healthcare reported January 22.

According to the article, policies attracting criticism include stringent prior authorization rules, claims denials, and new fees for appeals. For their part, insurance companies point to the need to constrain healthcare spending, also pointing to provider error and reimbursement process inefficiencies.
The article details multiple specific examples, including a controversial policy from Blue Cross Blue Shield of Michigan (BCBSM) to charge providers for unsuccessful appeals of rejected claims. While BCBSM argues this will reduce unnecessary appeals, providers fear it disincentivizes legitimate challenges to claim denials. Last year, 85% of BCBSM's claim denials were upheld by independent reviewers.

In another example, UnitedHealthcare has tightened requirements for molecular pathology tests, mandating providers include non-billing Z-codes with claims. As detailed in the article, the insurer claims this will streamline reimbursements and reduce appeals, but healthcare professionals argue it increases the administrative burden. The American Hospital Association (AHA) criticizes these changes, emphasizing that insurers’ efforts to control costs often impose inefficiencies on providers.
Citing a recent survey by KFF, Modern Healthcare reports that nearly one in five patients experienced a claim denial in the past year, and 74% of physicians report that prior authorization denials have surged in the last five years. The full report provide additional context, including details on efforts (some successful) by providers to push back.