In this week’s episode of the VHV podcast we’ll take a comprehensive look at utilization management (UM) and prior authorization (PA). Utilization management is the healthcare industry term for the various techniques health insurance companies employ to pay for care on their terms, according to their guidelines. Many times, their utilization management approach is in line with what physicians recommend. However, many times it is not. And when it’s not, patients suffer delays in their care and physicians and their staff end up mired in extra work to make sure their patients get the care they have determined is best.

In this timely episode, Dr. Anthony Paravati and Dr. Amar Rewari break down the healthcare implications of a Trump or Harris presidency. From prescription drug pricing and Medicare reforms to Medicaid block grants and the Affordable Care Act, this episode provides a nonpartisan, in-depth analysis of each candidate's position on healthcare. Discover what the future could hold for U.S. healthcare policies, costs, and patient access depending on the election's outcome. This is a can't miss episode before heading to the polls.

Drs. Anthony Paravati and Amar Rewari delve into the complexities of Medicare Advantage, exploring its appeal to seniors, the financial mechanisms behind its low premiums, and the challenges faced by providers. They discuss the demographics of Medicare Advantage enrollees, the revenue structures that sustain these plans, and the implications for healthcare providers. The conversation also highlights the pros and cons of Medicare Advantage for beneficiaries and speculates on the future sustainability of the program amidst tightening margins and regulatory pressures.takeaways

• Medicare Advantage offers lower premiums, appealing to budget-conscious seniors.
• The program is administered by commercial insurance companies, not the government directly.
• Narrow networks in Medicare Advantage can limit provider choices for seniors.
• Seniors with lower incomes are more likely to choose Medicare Advantage.
• Insurance companies benefit from risk adjustment payments for sicker patients.
• Quality bonuses incentivize Medicare Advantage plans to improve care.
• Hospitals face challenges with payment delays and denials from Medicare Advantage plans.
• The popularity of Medicare Advantage is increasing among seniors.
• Tighter margins for Medicare Advantage plans may lead to reduced benefits.
• Future changes in Medicare Advantage will depend on regulatory adjustments and market dynamics.