Massachusetts Health & Hospital Association

Prior Auth Enforcement; Migrants, Hospital Finances

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> Limiting Prior Auths in Mass. ….
> … And Nationally
> Hospital Finances
> Caring for Migrants
> ACHE of MA Equity Award
> Maintaining Telehealth
> Transition


Reducing Administrative Burdens on the State Level …

Working quickly, just weeks after passage of the comprehensive Mental Health ABC Act was signed into law, the state’s Division of Insurance (DOI) issued a bulletin mandating that commercial health insurance companies make fair payments and take shared responsibility for mitigating the state’s behavioral health crisis.

DOI’s Bulletin 2202-08 notes that “the number of individuals in crisis needing inpatient psychiatric treatment during the past two years has increased at the same time that inpatient bed capacity was reduced as a result of facility closures and necessary infection control measures.” As a result, the “boarding” of patients within hospitals has increased as they await an inpatient admission.

To help address the issue, DOI states in the bulletin that it expects health insurance companies to “reimburse acute care hospitals for appropriate behavioral healthcare delivered to patients in order to treat and stabilize their conditions.” Specifically, DOI says insurers are expected to reimburse acute care hospitals for patients in EDs, observation units, or medical surgical units awaiting inpatient psychiatric admission “at a level at least equivalent to crisis intervention mental health services as reimbursed by MassHealth.” Insurers are also directed to take steps to “forego prior authorization, concurrent, and retrospective medical necessity reviews for all ongoing monitoring and stabilization services” to patients requiring expedited psychiatric inpatient admissions.

The bulletin’s focus on implementing a payment to care for patients while they are awaiting an inpatient psychiatric bed , on reducing health-plan-imposed administrative burdens, and on compensating hospitals for medically necessary care are all goals MHA and its membership advocated for strongly with both the legislature and administration in the creation of the Mental Health ABC Act. Earlier in 2022, recognizing the need for resources to care for patients awaiting inpatient psychiatric care, MassHealth implemented a payment for such patients boarding in acute care hospitals. MassHealth also implemented several funding streams to support the inpatient behavioral health care system. MHA will be closely monitoring the subsequent development of regulations to implement the ABC Act.

… As Well As on the National Level

The U.S. House of Representatives, by voice vote last Wednesday, passed H.R. 3173, The Improving Seniors’ Timely Access to Care Act, which attempts to speed up the prior authorization process for Medicare Advantage plans. Part of the bill requires U.S. Health & Human Services to create a process to streamline authorization for routine items.

The bill follows an April Office of Inspector General report that found Medicare Advantage plans denied about 13% of the prior authorization requests that would have been routinely approved under original Medicare, also known as Medicare fee-for-service.

National Report Confirms State Findings on Hospital Finances

A new report from a national consulting group confirms what has been known in Massachusetts – hospitals took a large financial hit because of the pandemic, are still reeling, and the prospect for recovery under current conditions is not good.

The report from Kaufman, Hall & Associates, LLC, released last Thursday shows that under the most optimistic modeling for the entirety of 2022 margins will be down 37% compared to pre-pandemic levels, with more than half of hospitals operating in the red. Under a pessimistic scenario for the rest of 2022, margins could be down as much as 133% compared to pre-pandemic levels, with more than two-thirds of hospitals operating in the red.

The national report mirrors a report from earlier in 2022 from the state’s Center for Health Information and Analysis which found the statewide median operating margin for hospitals was negative 2.5%, even after including government relief funds they received. A subsequent MHA survey of hospitals this summer showed hospitals projected to expend nearly $1 billion in temporary R.N. staffing costs in 2022 – up from $181 million annually at the start of the pandemic in 2020.

The Kaufman Hall report projects that hospital and health system expenses are expected to increase national by nearly $135 billion in 2022 over 2021 levels with a large component of that deriving from expenses related to retaining and supporting the workforce. Employed labor expenses are projected to rise by $57 billion more than last year and contract labor by $29 billion. In fact, contract labor expenses alone are nearly 500% higher than pre-pandemic levels, which has played a significant role in driving expense growth for hospitals. The remaining $49 billion in added expenses in 2022 include those for supplies, drugs and equipment, which have all experienced significant growth from pre-pandemic levels.

The American Hospital Association, joined by MHA and other provider interests, are urging Congress to prevent further Medicare cuts from going into effect in 2023; extend or make permanent programs that provide support to rural hospitals; make critical waivers permanent; and hold commercial health plans accountable for policies that increase costs and delay access to medically necessary care.

Humanitarianism is at the Heart of Healthcare

The surprising political move by some border state governors to crowd migrants onto buses and airplanes and then send them unannounced to Massachusetts and other states has resulted in the commonwealth’s hospitals being called into service to provide shelter for the unexpected arrivals.

MHA’s President & CEO Steve Walsh said, “Our hospitals are working closely with local leaders to ensure that migrant families arriving to medical facilities are matched with the support services they need. Humanitarianism is at the heart of healthcare, and hospitals are proud to provide short-term refuge to anyone who enters their doors, even as those facilities navigate unprecedented capacity challenges. We will be closely tracking this situation along with our state and federal partners.”

Nominate Your Facility for ACHE Diversity Award

ACHE of Massachusetts will present its Fourth Annual Diversity Leader Award on November 1. The award highlights the efforts and progress that Massachusetts healthcare organizations have made to be as broadly diverse and inclusive as possible. All healthcare organizations in Massachusetts can apply for the 2022 award by informing ACHE on how they have created and initiated strategies in the following areas: and are implementing the following key criteria.

collection and use of diversity data; cultural competency training; diversity in governance and leadership; improving and strengthening community partnerships; inclusive health/wellness resources; incorporation of the diversity, equity, and inclusion lens into other business areas such as supplier diversity, investment portfolio, etc. Please note, success in all areas is not required to be considered for the award. The deadline for applications is October 3. Click here for more informationto submit a nomination, and to register for the November 1 event.

Concern Over the Changing Nature of Post-Pandemic Care

The Massachusetts Telemedicine Coalition (tMED), of which MHA is a founding member, is continuing its strong push for national policies that will make it easier for patients and providers to take advantage of the benefits of telemedicine.

Throughout the declared COVID-19 Public Health Emergency, hospitals have used what are known as remote partial hospitalization programs (remote PHP) to provide behavioral health services to patients whose access to care has been stymied by transportation, geography, or even adverse weather conditions. Remote PHP improves access for patients with challenging diagnoses, who can’t leave their homes to get outpatient care, and helps patients who are tied to their homes because they have responsibilities caring for other family members or their children. In its comments to the Centers for Medicare & Medicaid Services (CMS) regarding the FY2023 outpatient prospective payment system rule, tMED asked CMS to allow remote PHP beyond the end of the Public Health Emergency.

The outpatient rule also included a new requirement that patients receiving behavioral health services remotely then must receive in-person care within certain time frames for the provider to be reimbursed. tMED argued the in-person rule is impractical for a number of reasons, including there is no way a provider can ensure a patient will show up for follow-up care once they receive remote care.

CMS’s proposed outpatient rule is just one example of the changing nature of care now that the Public Health Emergency is ending and the flexibilities allowed under it may be phased out.


Montez Carter has been named president and CEO of Trinity Health of New England, effective October 3. He succeeds Reginald Eadie, M.D., who has held the leadership role since 2018 and who will now serve as SVP of Physician Enterprise Development for Michigan-based Trinity Health. Carter currently serves as president and CEO of St. Mary’s Health Care System in Georgia. He earned his doctoral degree in pharmacy from the University of Mississippi and his master’s degree in business administration from the University of Alabama.

John LoDico, Editor