Marilyn Heine Profile picture
Aug 26 6 tweets 3 min read Read on X
🧵”The AMA strongly supports the Department of Health and Human Services’ ⁦@HHSGov⁩ recent decision to upgrade #Medicare Plan Finder so patients can choose plans that actually include their trusted physicians and hospitals.” Image
2/ “This…mirrors AMA’s January 2025 advocacy calling for HHS to integrate plan network data into Plan Finder. Once this is complete, patients no longer will be forced to click through multiple websites just to confirm if their physicians are in-network.

tinyurl.com/5869nja2Image
3/ Patients can compare plans:

Medicare Advantage (Part C)
Medicare Prescription Drug (Part D)
Medigap plans at :

After entering zip code, meds, preferred pharmacies, the tool generates a list of plans available in the area, along with estimated costs.medicare.gov
4/📍AMA has:

• heard from patients struggling to navigate Plan Finder

• urged HHS to deliver a 1-stop tool where patients can:

-verify if a doctor or hospital is in network
-filter plans by specialty, location, language, hospital affiliation
-avoid post-enrollment surprises
5/📍AMA urges steps to ensure Plan Finder is user-friendly:

To ensure the upgraded Plan Finder is accurate and reliable, the AMA urges HHS to require Medicare Advantage plans to take these 7 steps ⤵️ Image
Image
6/ @PresAmerMed said:

“We commend HHS’ intent and commitments—and see this as a clear response to persistent @AmerMedicalAssn advocacy on behalf of physicians and our patients.”

Also ⤵️ Image
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More from @MarilynHeineMD

Aug 6
🚨As AMA’s representative to the HL7 Da Vinci Project Clinical Advisory Council (CAC), I ask that you please take urgent action.

Your participation could be the difference between meaningful improvements to prior authorization (PA) and little change.

Details in🧵

#FixPriorAuth Image
2/ **ISSUE OF CONCERN:

🔥On the PA and burden reduction use-case calls, some payers and EHR vendors are advocating that PA users should be back-office staff only, not clinicians based on their understanding and experiences.
3/

❗️Reliance on back-office is not the original intent of Da Vinci PA use-case design.

The goal was to have a clinician-oriented process that renders real time coverage information at the time of clinical decision and ordering to inform more timely and efficient PA workflows.
Read 8 tweets
Jul 31
🚨New AMA report analyzes the #pharmacybenefitmanager (#PBM) market concentration & its impact.

The report reviews the structure of the PBM industry, its deep ties to insurers, low level of competition, & high level of vertical integration.

👉 Report: 🧵 spr.ly/6047fnzfVImage
2/ AMA reports on the 10 largest PBMs & drug insurers nationally, summarizes concentration levels (HHIs) in their markets, & describes the extent of vertical integration of insurers with PBMs.

With ⬇️ competition & ⬆️ consolidation, patients could face ⬆️ costs & ⬇️ choices. Image
3/ The largest PBMs dominate a critical part of health care.

📍The 4 largest PBMs have a collective national market share of 67%.

📍OptumRx is the largest PBM (22.2% market share), followed by CVS Health (18.9%), Express Scripts (15.5%), & Prime Therapeutics (10.6%). Image
Read 9 tweets
Jul 21
🚨@AmerMedicalAssn conveyed to CMS concerns regarding the recently announced WISeR Model.

Read full letter:

Details “…key areas of concern where clarification and safeguards are needed to protect physicians and patients…”

Excerpts in 🧵 tinyurl.com/46msnsk8Image
2/ Wasteful and Inappropriate Service Reduction (WISeR) Model is a “…substantial shift in the traditional Medicare program’s approach to utilization management (UM) and prior authorization (PA)…potential for unintended consequences that could harm both patients and physicians.”
3/“…pathways represent significant departures from current standards & seem to conflict with CMS’ recent, highly laudable achievement of securing a commitment from the health insurance industry to fix the broken PA process, to include [⬇️] the overall volume of PA requirements.”
Read 28 tweets
Jul 16
🚨On 7/14/2025, CMS released the proposed rule for the 2026 Medicare Physician Fee Schedule Proposed Rule:

AMA identifies items for immediate attention as staff analyzes and develops a detailed summary of the nearly 2,000-page proposal. tinyurl.com/2p9t7w9xImage
2/🔹Conversion Factors (CF): Effects of MACRA, H.R. 1, Budget Neutrality

👉 MACRA Effect:

•Permanent 0.75% update for Medicare payments to QPs in advanced APMs

•Permanent 0.25% update for Medicare payments to all physicians who are not QPs, including MIPS-eligible clinicians
3/ Conversion Factors

👉 MACRA Effect:

•Physicians who are qualifying participants (QPs) in advanced APMs will receive a slightly ⬆️ CF update and, thus, slightly ⬆️ Medicare payments in 2026 compared to physicians who are not QPs.

tinyurl.com/3w48a8hfImage
Read 34 tweets
Jul 11
🚨CMS issued updates to its Risk Adjustment Data Validation (RADV) audit process aimed at strengthening oversight of Medicare Advantage (MA) payments to ensure accurate reflections of enrollees’ health status.

AMA has concerns about potential administrative burden on physicians. Image
2/ 🚨If you experience any new challenges related to increased RADV audit activity, the AMA encourages you to share your feedback with AMA to ensure they properly represent your concerns with the administration. Contact: Jamal.Bowleg@ama-assn.org
3/ Under the updated RADV framework, CMS will now audit all eligible MA contracts (approximately 550) annually.

Additionally, CMS aims to increase the number of records audited per plan from 35 to up to 200 per year.
Read 7 tweets
Feb 25
🔥 From AMA:

“Many physicians fear the #healthinsurance industry’s use of unregulated #artificialintelligence (#AI) automation and predictive technologies will increasingly override good medical judgment and systematically deny #patients coverage for necessary #medicalcare. “🧵 Image
2/ “According to a new survey from @AmerMedicalAssn, 3️⃣ in 5️⃣ physicians (61%) are concerned that health plans’ use of AI is increasing prior auth denials, exacerbating avoidable patient harms and escalating unnecessary waste now and into the future.”

👉 tinyurl.com/mt2h7dedImage
@AmerMedicalAssn 3/ “Burdensome #priorauthorization requirements that conflict with evidence-based clinical practices & create hurdles to patient access to safe, timely, & affordable treatment have been a major impediment to patient care for decades.”

Read @PresAmerMed statement⤵️

#FixPriorAuth Image
Read 6 tweets

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