A state of Connecticut-funded Medicare Advantage-focused study on plans’ utilization management (UM) and payment practices could yield findings relevant to LeadingAge’s national advocacy efforts. The initiative, according to the Connecticut Insurance Department’s March Request for Proposal, will examine the impact of plan UM and payment practices on hospital service delivery, costs to hospitals and MA plan members and will provide an analysis of the effects on other payers and access to services. In addition, the study will include a comparison of claim denials, modifications and reversals on appeal, across MA, Medicare, Medicaid and commercial payers. That work will inform the study’s recommendations on how to improve quality, access to care, timely care delivery, and payment policies.

On the latter, two recommendation focus areas caught our attention: how to reduce provider administrative costs associated with UM and “addressing payment practices that inappropriately reduce provider payments.”

While this is not a national study, we are hopeful that the undertaking may help to advance our advocacy efforts by exposing the lack of available MA data, the need for greater disclosure by plans, and highlighting how UM practices impact the entire health care system. That last item is an issue we have repeatedly brought to regulators’ attention over the past two years. MA plans continue to pay providers significantly less for Medicare services rendered, while at the same time maintaining their highly burdensome prior authorization processes that delay and deny necessary care – despite the intent of the CY2024 MA rules to improve these processes.

Following the selection of a vendor to conduct the study,  a final report will be submitted to the CT Department of Insurance by December 27, 2024.