The Medicare appeals backlog has become an intractable problem, troubling not only providers, but also administrative law judges (ALJs) and others within the Centers for Medicare & Medicaid Services (CMS). In December 2013, the Office of Medicare Hearings and Appeals (OMHA) suspended assignment of most new requests for ALJ hearings, which means it will take at least 30 months for an ALJ to adjudicate a newly submitted appeal of a Medicare claim denial. The problems inherent in the Medicare appeals system are beyond the control of providers and require action by OMHA and CMS.
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The Burden of Insurance Prior Authorization on Cancer Care: A Review of Evidence From Radiation Oncology.
Adv Radiat Oncol
January 2025
Department of Radiation Oncology, Vanderbilt University School of Medicine, Nashville, Tennessee.
Purpose: Despite its high cost-effectiveness, radiation oncology faces the greatest prior authorization (PA) burden of any medical specialty. Insurance denials and resulting treatment delays have been documented across several treatment modalities, including stereotactic body radiation, intensity modulated radiation, and proton therapy. Although insurance companies suggest that PA is intended to control health care spending and ensure the implementation of evidence-based practice, the number of radiation treatment plans reviewed by the PA process that result in changes is quite low.
View Article and Find Full Text PDFInappropriate Denials for Radiation Therapy in Medicare Advantage Plans.
Int J Radiat Oncol Biol Phys
November 2024
Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York; Department of Radiation Oncology, Herbert Irving Comprehensive Cancer Center, New York, New York.
Purpose: Radiation oncologists are known to be burdened with prior authorization and insurance denials more than other medical specialties. This analysis sought to use publicly available data and determine whether Medicare Advantage plans are inappropriately denying radiation therapy (RT) services more than other health services.
Methods And Materials: Data from the Appeals Decision Search on the Centers for Medicare & Medicaid Services website were extracted from 2022 through June 2024.
Assessing Private Equity Involvement in Ophthalmology: Parallels With the Past, Concerns for the Future.
Am J Ophthalmol
February 2025
Department of Ophthalmology (D.J.B.), Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA. Electronic address:
Purpose: To discuss the history and current state of private equity in ophthalmology, and to explore potential implications for ophthalmology practices, physicians, and patients.
Design: Perspective.
Methods: Selected articles in ophthalmology and non-ophthalmology medical literature were reviewed, and commentary is provided based on the authors' experiences.
Voter Support for Policies Associated With Child Health as National Campaign Priorities.
JAMA Health Forum
September 2024
Nemours Children's Health, Wilmington, Delaware.
Article Synopsis
- Child health policies are often overlooked in political candidate platforms, potentially due to a lack of awareness regarding voter support or the belief that these issues aren't divisive enough for partisan appeal.
- A nationwide survey conducted in early 2024 revealed that many voters are likely to support candidates who back child health initiatives, including Medicaid reform and the refundable child tax credit.
- Overall, significant support was noted among women and Democrats/Independents for child-focused policies, while Republican support was notably lower, with many respondents indicating they'd vote for candidates backing these policies.
The hierarchy of needs for laboratory medicine requires a foundational care delivery model.
Dialogues Health
December 2024
Department of Pathology and Laboratory Medicine, Diagnostics Institute, Cleveland Clinic, Cleveland, OH, United States of America.
Under the collective weight of growing test volume, staffing constraints, and Medicare reimbursements cuts, an enhancement-based, alternative payment structure focused on rewarding the laboratory's care delivery efforts via benchmarking is appealing. However, achieving a value-based payment model requires the development of an inclusive laboratory care delivery model (LCDM) framework. Today, a holistic, practical LCDM framework for laboratory medicine does not exist.
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