A Denial a Day Keeps the Doctor Away

Dunn, Abe; Gottlieb, Joshua D.; Shapiro, Adam Hale; Sonnenstuhl, Daniel J.; Tebaldi, Pietro

doi:10.2139/ssrn.3885053

Cited by 4 publications

(9 citation statements)

References 64 publications

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“…Research has demonstrated that of all payors, denial rates are the highest in fee-for-service Medicaid 61 and physicians lose more than one-sixth of Medicaid revenue to billing issues. 62 Further coverage restrictions may compound those concerns and, for Medicaid plans, reduce clinician willingness to participate and therefore reduce Medicaid beneficiary access. Medicaid beneficiaries often lack access to specialists (one-third of specialists do not accept publicly-insured patients).…”

Section: Challenges In Implementing Clinical Coverage Policy To Reduc...mentioning

confidence: 99%

“…Specifically in Medicaid, clinicians may already be concerned about low reimbursement rates and perceived high administrative burden. Research has demonstrated that of all payors, denial rates are the highest in fee‐for‐service Medicaid 61 and physicians lose more than one‐sixth of Medicaid revenue to billing issues 62 . Further coverage restrictions may compound those concerns and, for Medicaid plans, reduce clinician willingness to participate and therefore reduce Medicaid beneficiary access.…”

Section: Challenges In Implementing Clinical Coverage Policy To Reduc...mentioning

confidence: 99%

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A Policy Approach to Reducing Low‐Value Device‐Based Procedure Use

et al. 2022

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Low‐value care is common in clinical practice, leading to patient harm and wasted spending. Much of this low‐value care stems from the use of medical device‐based procedures. We describe here a novel academic‐policymaker collaboration in which evidence‐based clinical coverage for device‐based procedures is implemented through prior authorization‐based policies for Louisiana's Medicaid beneficiary population. This process involves eight steps: 1) identifying low‐value medical device‐based procedures based on clinical evidence review, 2) quantifying utilization and reimbursement, 3) reviewing clinical coverage policies to identify opportunities to align coverage with evidence, 4) using a low‐value device selection index, 5) developing an evidence synthesis and policy proposal, 6) stakeholder engagement and input, 7) policy implementation, and 8) policy evaluation. This strategy holds significant potential to reduce low‐value device‐based care.

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Section: Challenges In Implementing Clinical Coverage Policy To Reduc...mentioning

confidence: 99%

Section: Challenges In Implementing Clinical Coverage Policy To Reduc...mentioning

confidence: 99%

A Policy Approach to Reducing Low‐Value Device‐Based Procedure Use

et al. 2022

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“…Most perinatal providers will not schedule a prenatal care appointment until this step is completed. In addition, some prenatal care providers limit the number of Medicaid‐insured patients they accept, as Medicaid reimbursement for a standard prenatal visit is lower than private insurance reimbursement and requires a larger administrative burden 55 . Study participants described calling multiple providers to find one that would accept Medicaid insurance and waiting weeks for an appointment time 26,27,43 .…”

Section: Resultsmentioning

confidence: 99%

“…In addition, some prenatal care providers limit the number of Medicaid-insured patients they accept, as Medicaid reimbursement for a standard prenatal visit is lower than private insurance reimbursement and requires a larger administrative burden. 55 Study participants described calling multiple providers to find one that would accept Medicaid insurance and waiting weeks for an appointment time. 26,27,43 Often, these barriers overlapped with personal delays in care seeking, such as the late discovery of pregnancy or homelessness.…”

Section: Structural and Health System Barriers To Accessmentioning

confidence: 99%

A systematic review of the qualitative literature on barriers to high‐quality prenatal and postpartum care among low‐income women

Bellerose

Rodriguez

Vivier

2022

Health Services Research

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Objective: To examine the qualitative literature on low-income women's perspectives on the barriers to high-quality prenatal and postpartum care. Data Sources and Study Setting: We performed searches in PubMed, Web of Science, Embase, SocIndex, and CINAHL for peer-reviewed studies published between 1990 and 2021. Study Design: A systematic review of qualitative studies with participants who were currently pregnant or had delivered within the past 2 years and identified as lowincome at delivery. Data Collection/Extraction Methods: Two reviewers independently assessed studies for inclusion, evaluated study quality, and extracted information on study design and themes.Principal Findings: We identified 34 studies that met inclusion criteria, including 23 focused on prenatal care, 6 on postpartum care, and 5 on both. The most frequently mentioned barriers to prenatal and postpartum care were structural. These included delays in gaining pregnancy-related Medicaid coverage, challenges finding providers who would accept Medicaid, lack of provider continuity, transportation and childcare hurdles, and legal system concerns. Individual-level factors, such as lack of awareness of pregnancy, denial of pregnancy, limited support, conflicting priorities, and indifference to pregnancy, also interfered with the timely use of prenatal and postpartum care. For those who accessed care, experiences of dismissal, discrimination, and disrespect related to race, insurance status, age, substance use, and language were common.Conclusions: Over a period of 30 years, qualitative studies have identified consistent structural and individual barriers to high-quality prenatal and postpartum care. Medicaid policy changes, including expanding presumptive eligibility, increased reimbursement rates for pregnancy services, payment for birth doula support, and extension of postpartum coverage, may help overcome these challenges.

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“…For instance, healthcare organizations may experience more billing issues (eg, repealing claim denials) with Medicaid than with other payer types. 40,41 We grouped patients who had Medicare, Medicaid, or TRICARE as having a public payer. We also treated visits insured by a Medicare Advantage plan as having a public payer.…”

Section: Visit-level Covariatesmentioning

confidence: 99%

Early Performance of the Patients Over Paperwork Initiative among Family Medicine Physicians

Nguyen¹,

Hanna

Merlo

et al. 2023

Southern Medical Journal

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In 2019, the Centers for Medicare & Medicaid Services began implementing the Patients Over Paperwork (POP) initiative in response to clinicians reporting burdensome documentation regulations. To date, no study has evaluated how these policy changes have influenced documentation burden.Methods: Our data came from the electronic health records of an academic health system. Using quantile regression models, we assessed the association between the implementation of POP and clinical documentation word count using data from family medicine physicians in an academic health system from January 2017 to May 2021 inclusive. Studied quantiles included the 10th, 25th, 50th, 75th, and 90th quantiles. We controlled for patient-level (race/ethnicity, primary language, age, comorbidity burden), visit-level (primary payer, level of clinical decision making involved, whether a visit was done through telemedicine, whether a visit was for a new patient), and physician-level (sex) characteristics.Results: We found that the POP initiative was associated with lower word counts across all of the quantiles. In addition, we found lower word counts among notes for private payers and telemedicine visits. Conversely, higher word counts were observed in notes that were written by female physicians, notes for new patient visits, and notes involving patients with greater comorbidity burden.Conclusions: Our initial evaluation suggests that documentation burden, as measured by word count, has declined over time, particularly following implementation of the POP in 2019. Additional research is needed to see whether the same occurs when examining other medical specialties, clinician types, and longer evaluation periods.

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A Denial a Day Keeps the Doctor Away

Cited by 4 publications

References 64 publications

A Policy Approach to Reducing Low‐Value Device‐Based Procedure Use

A Policy Approach to Reducing Low‐Value Device‐Based Procedure Use

A systematic review of the qualitative literature on barriers to high‐quality prenatal and postpartum care among low‐income women

Early Performance of the Patients Over Paperwork Initiative among Family Medicine Physicians

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