Consumer Engagement

Three major health insurers have denied allegations brought against them in lawsuits pertaining to the use of artificial intelligence in coverage decisions. While The Cigna Group, Humana Inc. and UnitedHealth Group may succeed in getting the cases dismissed, those companies and other payers could continue to face scrutiny over their use of AI, according to Ileana M. Hernandez, a partner at Manatt, Phelps & Phillips, LLP.

“The staggering volume of claims and complexity of claims that insurance plans need to review on a daily basis make insurance reviews an attractive target for using AI,” said Hernandez, who spoke on June 12 during a Manatt webinar. “However, the use of algorithms for review of coverage issues has resulted in questions, concerns, investigations and now lawsuits.”

There are persistent challenges around the collection and transmission of that data between providers and payers. The same is true of the quality of the data itself. It's a key challenge for the health insurance industry as payers try to measure provider quality and transition to value-based contracting.

"I'll just say the accuracy of our directory is bad. It just is," said Mike Kane, senior vice president for provider data operations at UnitedHealthcare. Kane was speaking on a June 12 panel organized by the Council for Affordable Quality Healthcare (CAQH) at the 2024 AHIP Conference in Las Vegas. "About half of every single provider [data profile] that our members call, there's at least one data element in our directory that's wrong."

"It's a horrible, horrible experience," Kane said.

Although overall customer satisfaction rankings improved year over year in the J.D. Power 2024 U.S. Commercial Member Health Plan Study, nearly all evaluated health plans struggled to provide a high-quality digital customer experience. Indeed, one perennially high-performing plan admits that it, too, has been striving to solve the digital-experience puzzle — but it hopes that a new affiliation agreement will help by adding much-needed scale and access to capital.

This year’s J.D. Power survey measured satisfaction among 29,188 members of 147 group and individual health plans in 22 regions throughout the U.S. from January to April 2024. Plans are scored based on performance in eight core dimensions: “able to get health services how/when I want,” “digital channels,” “ease of doing business," “helps save time and money,” “people,” “product/coverage offerings,” “resolving problems or complaints” and “trust.”

UnitedHealth Group’s Surest brand has become a hot product in recent months, with sales of the alternative benefit design accounting for one third of the health care giant’s new commercial business, according to some accounts. UnitedHealthcare, the firm’s managed care arm, pitches commercial clients on Surest by promising lower costs and higher quality — without sacrificing a broad network.

Alternatives to conventional PPO plans are more appealing than ever for commercial insurance plan sponsors, who have struggled with sharp medical cost and premium increases in recent years. But restrictive narrow network plans are often unpopular with plan members, and payer stakeholders have begun to shy away from models that shift costs to members.

Amid an ongoing mental health crisis that has seen a near 40% increase in patients grappling with mental health conditions since 2020, Centene Corp.’s WellCare of Kentucky launched a pilot program to address two conditions — panic attacks and post-traumatic stress disorder (PTSD) — that are often overlooked.

Working with digital therapeutics company Freespira Inc., the pilot program takes an innovative approach to managing conditions at home with supportive technology and personalized coaching. AIS Health, a division of MMIT, connected with leaders of the two organizations, Timothy Houchin, M.D., a board-certified adult, child and forensic psychiatrist and senior medical director for WellCare Kentucky, and Joseph Perekupka, CEO of Freespira, to discuss the collaboration and learn about the early outcomes.

Sen. Ron Wyden (D-Ore.), Chair of the Senate Finance Committee, wrote a letter on May 20 to CMS Administrator Chiquita Brooks-LaSure urging the agency to fine unscrupulous health insurance brokers. Wyden sent his letter following a CMS statement earlier this month that the agency had received about 40,000 complaints that people had been switched from one Affordable Care Act marketplace plan to another without their consent during the first three months of this year. CMS also said it had received about 50,000 complaints of unauthorized enrollments in plans in January, February and March. Wyden noted that the Affordable Care Act contains a provision that allows for penalties of up to $250,000 for “individuals who submit fraudulent information for a qualified health plan” in a “knowing and willful” manner. He wrote that “I am disappointed these penalties have not yet been used to hold bad actors accountable.” Wyden added in his letter that “the brokers, agencies and lead generators participating in fraudulent enrollment schemes should be held criminally responsible. While CMS does not have this authority today, I intend to introduce legislation shortly to give you this authority.”

CMS on May 9 extended through June 2025 waivers meant to help states and Medicaid managed care organizations navigate the unwinding of COVID-19 pandemic-related eligibility rules. The waivers, which include provisions allowing MCOs to reach out to members about redeterminations and help members complete eligibility paperwork, were originally set to expire in January 2025.

The extension of the waivers — specifically, 1902 (e)(14) waivers — could help MCOs leave behind the upheaval caused by the return of eligibility redeterminations, which resumed in spring 2023 after a multiyear pause tied to the COVID-19 public health emergency. The crush load of eligibility checks has been difficult for states to manage. Many states disenrolled eligible Medicaid beneficiaries for administrative reasons, typically because the beneficiary made an error in their eligibility check or didn’t return paperwork in time to meet a redetermination deadline. The chaos, which was the subject of mutual recrimination between states and CMS, has caused no shortage of headaches for MCOs.

Emerging technologies such as artificial intelligence (AI) are being incorporated into numerous processes within the health care system with an eye on improving a wide range of results. But rather than applying them across the board, a balance must be struck between what tasks are best suited for automation and what work best when provided with a human touch.

When it comes to patient onboarding, for instance, automated solutions may help fulfill certain requirements quickly, allowing patients to start needed therapies soon. But adherence to those treatments may be better achieved with a human touch that can help personalize approaches.

As Medicare Part D sponsors consider critical steps to setting up the new Medicare Prescription Payment Plan (M3P), CMS is weighing feedback from stakeholders on various aspects of the program, from beneficiary communications to pharmacy interactions. And some warned that potential beneficiary confusion may lead to increased complaints that impact plans’ Star Ratings.

The M3P, which takes effect on Jan. 1, 2025, requires both stand-alone Prescription Drug Plan and Medicare Advantage Prescription Drug carriers to give beneficiaries the option to spread their pharmacy costs over the plan year via a capped monthly payment. CMS in February issued its second draft guidance on the M3P and asked for comments no later than March 16. CMS plans to release the final guidance this summer. The agency sought comment on model materials issued through an Information Collection Request (ICR), including a standardized notice that plans would be required to use for targeted outreach to enrollees who are likely to benefit from the M3P. The initial 60-day comment period on the model materials ended April 29; CMS said it expects to issue a second, 30-day comment period in Spring 2024.

For the first time ever, Medicare Part D beneficiaries in 2025 will have the opportunity to spread their prescription drug expenses over the course of the plan year. While Part D sponsors must offer the option to enrollees effective Jan. 1, 2025, plans face multiple considerations and tasks prior to then. One of their most immediate concerns, industry experts say, is factoring in potential administrative costs and/or financial losses associated with the new Medicare Prescription Payment Plan (M3P, as many are calling it) into bids due next month.

Created under the Inflation Reduction Act, the M3P requires stand-alone Prescription Drug Plans and Medicare Advantage Prescription Drug plans to give enrollees the option to pay out-of-pocket prescription drug costs in the form of capped monthly payments versus paying the full amount at the pharmacy. Program participants will pay $0 at the pharmacy but receive a monthly bill from their Part D carrier, which must reimburse the pharmacies in full.