We all know that Medicare "Advantage" is a racket. I don't understand why traditional Medicare would be modified to be more like this racket. Prior authorization is just one of the nasty things MA has been imposing on the public. Their narrow networks of inferior practitioners is yet another.
This is exactly what United Health (insurance company) does... And was exposed forth fraud after their CEO was shot. They want to take money from the Medicare trust fund and pay these private companies to deny health care. Atrocious.
We MUST protest LOUDLY and FORCEFULLY and IMMEDIATELY. Call your Congressmen and call your Senators.... Today and every day here's the number for the Capitol switchboard. They'll connect you. 202-224-3121
Bernie Sanders will have plenty to say about this but we cannot depend on Bernie to fight this alone.
CMS is complicit in the denial of /delay in care that caused an eye infection to become a chronic condition for me. How absurd can this be when the body that is supposed to regulate the Health Insurance Companies is creating problems for patients. With the Big UGLY Budget law passed, I am concerned that privatization of Medicare (dis)Advantage, Medicaid, and the ACA will only become worse for American patients and a further strain on the Medicare Trust Fund. Our US Senators are doing a major disservice to the general public and they should be held accountable in the 2026 mid-term elections.
A question. Not for you, Rachel, tho it may be one you're asking yourself. If AI is so terribly (pun intended) good, then why do they need to require prior authorization?
The law and regulations currently make it impossible for a provider who chooses to provide a service that they know will not be covered to bill the beneficiary. (Please know that it is a rhetorical question I'm working up to.)
EMTALA requires a provider to 'stabilize' a patient without inquiring into the patient's coverage. And Medicare covers reasonable and necessary care under what is, at least, a 'prevailing practice' standard of 'reasonable and necessary care'?
So why would a provider, acting in good faith, in the best interest of the patient, who believes that the service they are providing is necessary and reasonable to prevent injury to the patient, and without any intent to defraud the Medicare program NOT proceed to provide that care?
Because Medicare refuses to provide, in my humble non-clinical opinion, actionable definitions of when services are, are not, and may or may not be necessary. Any service that 'may or may not' be necessary is—by any logic of which I'm aware—necessary.
Which is why Medicare has not to this point required prior authorization. Prior authorization can result in delays in treatment that do result in injury to patients.
So, to return to my question, if AI can validly (important word) determine whether the service is necessary — and CMS can provide evidence that the AI determinations are 99.9% sensitive and 99.9% specific—then why should prior authorization require more than a few milli-seconds?
More to the point, if their algorithms are so good, then why can CMS not use them to identify the providers that are not acting in good faith and who are recommending services they they know or should know are not necessary with the intent to defraud Medicare and suspend their participation in Medicare in the "sure and certain" knowledge that the suspension will withstand legal challenge?
I won't apologize for this rant because — as a long time (frustrated) user of Medicare's National and Local Coverage Guidance — this is a question that I've been waiting to hear an answer to for more than 40 years.
I've already been hit with a prior authorization with traditional Medicare for a spinal nerve block that caused me to suffer for three months. I had to get two nerve block tests in the same-day surgical center a month apart and fail physical therapy. Yes, it was expensive and painful. I have a long history of successful nerve blocks. SMH #BadPolicy
It's been in the works for awhile. Check out the ACO REACH program. Medicare's ACO-REACH allows private equity firms & Wall Street companies to take up to 25%+ of every Medicare $1 for admin. & profits 4 managing Medicare claims. It's thievery of Medicare public money that imposes an unnecessary behind-the-scenes gatekeeper for medical care. Beneficiaries don't have access to the process, in fact don't even know it exists!
I assume you are taking back your snarky “republicans” comment, given that the model Kathy Powers informed you of has been in place since 1/1/23, with the original announcement coming in February of 2022?
We all know that Medicare "Advantage" is a racket. I don't understand why traditional Medicare would be modified to be more like this racket. Prior authorization is just one of the nasty things MA has been imposing on the public. Their narrow networks of inferior practitioners is yet another.
ABSOLUTELY NOT.
This is exactly what United Health (insurance company) does... And was exposed forth fraud after their CEO was shot. They want to take money from the Medicare trust fund and pay these private companies to deny health care. Atrocious.
We MUST protest LOUDLY and FORCEFULLY and IMMEDIATELY. Call your Congressmen and call your Senators.... Today and every day here's the number for the Capitol switchboard. They'll connect you. 202-224-3121
Bernie Sanders will have plenty to say about this but we cannot depend on Bernie to fight this alone.
Who is behind this? Lobbyists are paying off Congressmen.
CMS is complicit in the denial of /delay in care that caused an eye infection to become a chronic condition for me. How absurd can this be when the body that is supposed to regulate the Health Insurance Companies is creating problems for patients. With the Big UGLY Budget law passed, I am concerned that privatization of Medicare (dis)Advantage, Medicaid, and the ACA will only become worse for American patients and a further strain on the Medicare Trust Fund. Our US Senators are doing a major disservice to the general public and they should be held accountable in the 2026 mid-term elections.
This just stinks! Type 1 diabetes, using tech which I’m sure will be questioned, they’re already wanting only generic insulins. Boo hiss
More corporate welfare will be in budget
because this Republican administration appointed pro-corporation persons to CMS. Passing
Medicare for all we save thousands of lives and hundreds of billions of dollars and will-prevent 500,000 medical bankruptcies every year.
Your posts as well as others subscribed to don't show up in my notes/feed, although liking recent posts. Substack's chat gives nonsensical answers.
SMH
A question. Not for you, Rachel, tho it may be one you're asking yourself. If AI is so terribly (pun intended) good, then why do they need to require prior authorization?
The law and regulations currently make it impossible for a provider who chooses to provide a service that they know will not be covered to bill the beneficiary. (Please know that it is a rhetorical question I'm working up to.)
EMTALA requires a provider to 'stabilize' a patient without inquiring into the patient's coverage. And Medicare covers reasonable and necessary care under what is, at least, a 'prevailing practice' standard of 'reasonable and necessary care'?
So why would a provider, acting in good faith, in the best interest of the patient, who believes that the service they are providing is necessary and reasonable to prevent injury to the patient, and without any intent to defraud the Medicare program NOT proceed to provide that care?
Because Medicare refuses to provide, in my humble non-clinical opinion, actionable definitions of when services are, are not, and may or may not be necessary. Any service that 'may or may not' be necessary is—by any logic of which I'm aware—necessary.
Which is why Medicare has not to this point required prior authorization. Prior authorization can result in delays in treatment that do result in injury to patients.
So, to return to my question, if AI can validly (important word) determine whether the service is necessary — and CMS can provide evidence that the AI determinations are 99.9% sensitive and 99.9% specific—then why should prior authorization require more than a few milli-seconds?
More to the point, if their algorithms are so good, then why can CMS not use them to identify the providers that are not acting in good faith and who are recommending services they they know or should know are not necessary with the intent to defraud Medicare and suspend their participation in Medicare in the "sure and certain" knowledge that the suspension will withstand legal challenge?
I won't apologize for this rant because — as a long time (frustrated) user of Medicare's National and Local Coverage Guidance — this is a question that I've been waiting to hear an answer to for more than 40 years.
This is the work of trumps and his vile henchmen (like charlatans Dr Oz and uncle Bobby) to further deny health care coverage to average Americans!!
It’s hilarious when non-technical PHD’s try to talk tech.
AI in PA? 😂
Why?
What exactly would one do with that which couldn’t be done with an API call to a database, be it relational, star schema, ODS, NoSQL, etc.?
Definitely riled up the boomers though 😂😂
Unbelievable 🤦♂️
It’s a great time to end profit-making health insurance companies with their prior authorizations and their incentive to deny care to boost profits.
I've already been hit with a prior authorization with traditional Medicare for a spinal nerve block that caused me to suffer for three months. I had to get two nerve block tests in the same-day surgical center a month apart and fail physical therapy. Yes, it was expensive and painful. I have a long history of successful nerve blocks. SMH #BadPolicy
This is beyond corporate welfare, with Republicans in charge our healthcare is organized crime.
It's been in the works for awhile. Check out the ACO REACH program. Medicare's ACO-REACH allows private equity firms & Wall Street companies to take up to 25%+ of every Medicare $1 for admin. & profits 4 managing Medicare claims. It's thievery of Medicare public money that imposes an unnecessary behind-the-scenes gatekeeper for medical care. Beneficiaries don't have access to the process, in fact don't even know it exists!
Thank you Wall Street for more chronic disease in humans and global warming in Earth
I assume you are taking back your snarky “republicans” comment, given that the model Kathy Powers informed you of has been in place since 1/1/23, with the original announcement coming in February of 2022?