AHA - Addressing commercial health plan challenges to ensure fair coverage for patients and providers

November 7, 2022

Table of Contents

  1. Executive Summary
  2. Introduction
  3. Prior Authorization
  4. Reimbursement Delays and Denials
  5. Policy Solutions
  6. Conclusion
  7. Endnotes

Executive Summary

[View in PDF.]

Hospitals and health systems are committed to ensuring timely patient access to medically necessary health care services. Comprehensive health care coverage is a critical tool to help individuals and patients access and finance their care. This is why hospitals and health systems have long advocated for a robust system for universal coverage rooted in our long-standing public-private model that relies on a strong commercial health insurance market alongside the Medicare and Medicaid programs.

However, while some health insurers provide value thorough collaboration with providers and their enrollees, many others are increasingly adopting policies and practices that contribute to delays in patient care and place undue burdens on both enrollees and health care providers. Many of these practices also add unnecessary costs to the health care system. In a recent survey of members, the AHA learned that 78% of hospitals and health systems’ experience working with commercial insurers is getting worse, not better.

Patients should be able to rely on their health insurance plan to facilitate covered, medically necessary health care services when they need it without delays or inappropriate denials, and clinicians should be able to focus on caring without burdensome obstacles. This report explores why more oversight is needed to ensure appropriate patient access to care and reduce unnecessary cost and burden.

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