Thompson Coburn partner Mackenzie Wallace was the featured guest on a recent episode of AHLA’s Speaking of Health Law Podcast, where she sat down with Bob Paskowski, Consulting Principal, PYA, to discuss the latest trends and challenges facing the provider and payer in today’s health care market. Mackenzie and Bob discussed some of the practical recommendations they give clients who are trying to navigate the current landscape, OIG’s April 2022 report addressing Medicare Advantage denials of prior authorization requests, the impact of the No Surprises Act’s (NSA) independent dispute resolution process and much more.

The episode lays out the significant challenges in the health care market on both the provider side and the payer side. On the provider side, the pair points out that the health systems and physician groups are facing significant headwinds and challenges specifically on their expense side of the business. Challenges include labor shortages both on the clinical and the administrative side and increased supply costs. On the payer side, they say issues include trying to keep costs down and not succumbing to a request for a rate increase. 

Mackenzie said there are a lot of discussions in the industry about inflation, the cost of health care and the burden on consumers. However, she said, “There was not a lot of discussion about this particular issue, which is provider and payer issues and how it impacts that intersection of cost and value and inflation.” The provider a d the payer need to create solutions to lessen some of the concerns and decrease the administrative burden that further drives costs up for all of the parties involved.

Mackenzie also discussed the OIG report that was issued in April 2022 that addressed Medicare Advantage denials of prior authorization requests and raised concerns about beneficiary access to medically necessary care. She said there are a certain percentage of claims where no mistake by the provider was made, and these claims are still not being paid properly because a different rubric is being applied than what is legally required. Mackenzie said, “And that is really relevant to the underlying dispute because when that occurs, it increases heavily the administrative burden for the providers to get paid. And the end result is the fight that really led to the NSA, which is that consumers are paying too much.”