News from the South - Alabama News Feed

States try to rein in health insurers’ claim denials, with mixed results

Published

3 months ago

March 25, 2025

Staff Editor

alabamareflector.com – Shalina Chatlani – 2025-03-25 18:01:00

by Shalina Chatlani, Alabama Reflector
March 25, 2025

This story originally appeared on Stateline.

Health insurance companies are under increasing scrutiny for allegedly using artificial intelligence bots and algorithms to swiftly deny patients routine or lifesaving care — without a human actually reviewing their claims.

The high-profile killing late last year of UnitedHealthcare CEO Brian Thompson has focused even more attention on so-called prior authorization, the process by which patients and doctors must ask health insurers to approve medical procedures or drugs before proceeding. There had been protests and outrage over the company’s practices for months before Thompson’s death, and UnitedHealthcare has been accused in a class-action lawsuit of using AI to wrongfully deny claims.

As more patients and doctors voice their frustrations, states are responding with legislation designed to regulate prior authorization and claims reviews. So far this year, lawmakers in more than a dozen states are considering measures that would, for example, limit the use of AI in reviewing claims; exclude certain prescription medications from prior authorization rules; ensure that emergency mental health care is not delayed for more than 48 hours; and require that insurers’ review boards include licensed physicians, dentists or pharmacists with clinical experience.

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Insurers have long required doctors to obtain their approval before they’ll pay for certain drugs, treatments and procedures. They argue it is necessary to rein in health care costs and limit unnecessary services. But many doctors and patients say the practice has gotten out of hand, causing delays and denials of care that are harming and even killing people.

In a survey last year by the American Medical Association, 93% of doctors said that insurers’ prior authorization practices delayed “necessary care” for their patients. Twenty-nine percent said such delays had led to a “serious adverse event,” such as hospitalization, permanent injury or death.

In 2023, insurers selling plans on the marketplaces created under the Affordable Care Act denied a combined average of 20% of all claims. Of the 73 million in-network claims they denied, only 1% were appealed, according to KFF, a health policy research group.

The federal role

Under the Biden administration, the Federal Trade Commission and the Department of Justice took a firmer hand against health care corporations alleged to be engaging in behavior resulting in limited and more expensive care for patients. The administration also approved rules requiring that beginning in 2026, Medicare and Medicaid plans create a streamlined electronic process for reviewing claims, making decisions more quickly and providing specific reasons for denying care.

But it’s difficult to hold insurers accountable, according to Timothy McBride, a health policy analyst and co-director of a program at the Institute for Public Health at Washington University in St. Louis.

“Each part of the health care industry — hospitals, pharmaceuticals, insurers — they all have a lot of concentrated power,” McBride said in a phone interview. “And unless somebody actually takes it on directly, it’s going to stay that way. I think the Biden administration tried to take it on, but didn’t make a lot of progress.”

It’s unclear whether the Trump administration and Congress will reverse course. During his confirmation hearing on March 14, Dr. Mehmet Oz, President Donald Trump’s pick to lead the Centers for Medicare & Medicaid Services, defended the use of artificial intelligence in reviewing claims.

“AI can be used for good or for evil, and it to a large extent depends on who’s using it and for what purpose,” Oz told members of the U.S. Senate Finance Committee. “I think AI could play a vital role in accelerating preauthorization.”

In the past, Trump has supported measures to help patients, such as increasing hospital price transparency and lowering prescription drug prices, McBride noted. But “Republicans and conservatives generally are anti-regulation,” he said. “My gut feeling would be that they back off on the Biden push on this.”

States have limited power to act on their own. They have authority only over state-regulated health plans, which include Medicaid, plans for state workers and policies residents purchase from the ACA marketplaces. About 90 million people are covered that way. State laws do not apply to the 156 million workers, retirees and dependents who get their coverage through employer-sponsored health plans, which are regulated through a federal law known as ERISA.

Furthermore, health insurance companies are large and have deep pockets, allowing them to easily absorb state fines.

But Kaye Pestaina, the director of the program on patient and consumer protection at KFF, said states have an important role to play.

“Much of the focus around prior authorization at the federal level has kind of originated from state protections, so I imagine there will be continual activity by state legislatures to come at the problem,” Pestaina told Stateline.

What states are doing

Pestaina said states are trying a number of solutions. For example, states such as Arizona, Michigan and Pennsylvania have given their insurance regulators more authority to directly access claims denial information, in order to overturn decisions or potentially enforce state rules. And these efforts have largely had bipartisan support.

There is a role for some oversight to make sure that things are covered. But right now, I think the system is out of balance.

– North Carolina Republican state Rep. Timothy Reeder

In Pennsylvania, Republican state Sen. Kristin Phillips-Hill pushed through bipartisan legislation in 2022 to streamline prior authorization practices for state-regulated health plans after hearing numerous complaints from patients and doctors.

The legislation created an Independent External Review organization that allows Pennsylvanians to submit an online form to request a review if their insurer denies a service or treatment. If the review organization decides the service should be covered, the insurer must do so. Before then, patients could turn only to a federal review process, which may have been more challenging to navigate and taken more time.

“Our reforms created clear rules, clear timelines for the prior authorization process, and it removed ambiguity or uncertainty from the system that at times, insurers could exploit and providers could be confused over,” Phillips-Hill told Stateline. “Prior to that reform, if you had a denial from your insurer, you had very little recourse.”

The program began in January 2024, and in its first year the Pennsylvania Insurance Department overturned half of 517 denials, which amounted to claims from 259 people.

Jonathan Greer, president and CEO of the Insurance Federation of Pennsylvania, said his trade group worked with lawmakers to come to an agreement on how to change the prior authorization process in a way that worked for insurers and patient advocates. Greer says he thinks Pennsylvania could be a model for other states.

“Prior authorization, I think unfairly, has been characterized as a reason to say ‘no’ by insurers,” Greer said. “The purpose of prior authorization is to make sure that you know the care that you get is consistent with the care that you need.”

In North Carolina, Republican state Rep. Timothy Reeder is hopeful that his prior authorization bill will make it across the finish line this year. Reeder’s bill would set tight deadlines on insurers’ claim decisions and require companies to have licensed practitioners on their claim review boards. Insurers would also have to publicize a list of services they require authorization for.

“I’m not saying that we need to get rid of it completely,” Reeder told Stateline. “There is a role for some oversight to make sure that things are covered. But right now, I think the system is out of balance.”

But some state laws have proven to be less effective than advertised.

In 2021, Texas enacted a first-of-its-kind law creating a “gold card” standard, under which physicians whose care recommendations are approved by insurers at least 90% of the time are exempt from the prior authorization process. But as of the end of 2023, only 3% of Texas physicians had earned gold card status, according to the Texas Medical Association.

That’s why the group is pushing legislation that would require insurers to report which preauthorization exemptions they granted and denied and how many claims went to independent review. Dr. Zeke Silva of the Texas Medical Association’s legislative council said it would be “in the same spirit” as what Pennsylvania has done.

“Our focus with the [Texas Medical Association] is our physicians being able to provide the best care possible. And we want that to be free of burden,” Silva told Stateline. “We want to minimize third parties coming in and inappropriately denying care that our physicians and our patients think is in their best interest.”

Stateline reporter Shalina Chatlani can be reached at schatlani@stateline.org.

Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org.

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Alabama Reflector is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Alabama Reflector maintains editorial independence. Contact Editor Brian Lyman for questions: info@alabamareflector.com.

The post States try to rein in health insurers’ claim denials, with mixed results appeared first on alabamareflector.com

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In polluted Birmingham community, Trump terminates funding for air monitoring

Published

1 day ago

June 15, 2025

Staff Editor

alabamareflector.com – Lee Hedgepeth, Inside Climate News – 2025-06-15 07:01:00

by Lee Hedgepeth, Inside Climate News, Alabama Reflector
June 15, 2025

This article originally appeared on Inside Climate News, a nonprofit, non-partisan news organization that covers climate, energy and the environment. Sign up for their newsletter here.

BIRMINGHAM — When Jilisa Milton received the grant termination letter, she wasn’t surprised. She suspected this day would come.

The language the Greater Birmingham Alliance to Stop Pollution (GASP) had used in its application to the Environmental Protection Agency had been clear. “We’re talking about helping a community,” Milton, GASP’s executive director, said last week, “where Black people have been disproportionately impacted.”

Black residents had breathed heavily polluted air from a nearby coke plant for decades, and their neighborhoods had been declared a federal hazardous waste Superfund site after it was determined that waste soil laced with arsenic, lead and benzo(a)pyrene, a human carcinogen, from several nearby coke plants had been spread around their homes as yard fill.

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In light of this history and continued industrial pollution, GASP had obtained a $75,000 air monitoring grant from the Biden EPA in 2023.

Milton received the letter earlier this month from officials in President Donald Trump’s EPA terminating the grant because it no longer aligned with the agency’s priorities.

“I knew at some point they would notice the language of our grant,” Milton said, in that it made reference to services intended to help Black people.

Still, she said she doesn’t regret the way GASP characterized the situation on the ground in north Birmingham—that the need for air monitoring stemmed from the city’s history of corporate exploitation of majority-Black workers and residents.

Growing up in Birmingham, Milton said her grandparents often discussed the legacy of workers in the Magic City—so-nicknamed because of the seemingly supernatural economic boom spurred by steel production following the end of the Civil War.

“The majority of these workers were Black, and we can see the disparate impact that still has today,” Milton said. “And it’s really important for Birmingham to talk about our legacy and our history.”

Sanitizing that history, then, to comply with the Trump administration’s stated opposition to all things DEI and environmental justice—as if they were the same thing, just because they both often involve Black people—doesn’t sit well with her.

“I think the narrative work is gone then,” Milton said. “And we have to think about history so we don’t live it again.”

The grant, awarded through EPA’s small grants program, was set to fund GASP’s efforts to train residents in using air monitoring equipment to help establish a community air monitoring program, allowing those in north Birmingham access to critical information about the pollutants filling their lungs every day.

In addition to what is now the 35th Avenue Superfund site, encompassing the neighborhoods of Collegeville, Harriman Park and Fairmont, north Birmingham remains home to several polluters, leaving its residents in the 90th percentile for particulate matter, according to EJ Screen, a government tool also recently shuttered by the Trump administration.

That context of present and past pollution was what made securing funds for air monitoring so important, Milton said, giving residents an opportunity to learn more about the continued impact of industry on their health.

“For decades, residents of North Birmingham and other historically marginalized communities have been forced to live in the shadow of toxic industries with little support or transparency,” Milton wrote in a statement after receiving the termination letter. “The grant made it possible for us to monitor and document the pollution people live with everyday. Revoking this support sends a message that the health of Black, Brown, and low-income communities in Alabama is disposable.”

In its letter, EPA officials said the agency no longer supported the grant’s objectives.

“The purpose of this communication is to notify you that the U.S. Environmental Protection Agency (EPA) is hereby terminating Assistance Agreement No. EQ-02D22522 awarded to GASP,” the letter said. “This EPA Assistance Agreement is terminated in its entirety effective immediately on the grounds that the award no longer effectuates the program goals or agency priorities. The objectives of the award are no longer consistent with EPA funding priorities.”

Piles of coal and coke waste remain on the ground at the Bluestone Coke in Birmingham nearly three years after the plant closed. (Lee Hedgepeth/Inside Climate News)

GASP’s isn’t the only environmental justice effort in Alabama nixed by federal officials. In April, Trump announced the termination of what the administration termed an “illegal DEI” settlement aimed at addressing sewage issues in the state’s black belt that have left its majority-Black residents sometimes unable to flush their own toilets.

The agreement, reached under the Biden Administration, required the state’s Department of Public Health to improve sanitation efforts in the region. It’s still unclear what that termination will ultimately mean on the ground.

In the end, Milton said the impact of the administration’s decision to terminate the north Birmingham air monitoring grant is racist.

“Look at the way they talk about environmental justice,” she said of administration officials. “They say it’s illegal to address these issues. So you hear the things they say, and it’s reasonable to discern from that that the impact is racist, and that what they’re doing is intentional.”

People of all races are forced to face the consequences of polluted air and water, Milton emphasized, but ignoring the reality that people of color have borne and continue to bear the brunt of industrial exploitation isn’t helpful. In fact, she explained, doing so could undermine the relationship organizations like hers have built with residents of color living through the impacts of pollution every single day.

“I don’t want to sacrifice the trust we have in communities that want to be heard because they notice that we start to change the way we talk about these issues,” she said. “Because they are the most important stakeholders. They’re who we’re here to serve.”

Moving forward, GASP plans to appeal the termination with EPA officials, Milton said, though she suspects the agency is unlikely to change its mind. If that’s the case, the nonprofit will do what they’ve always done—look to individual donors to fill in the gaps. It’s work that can’t be abandoned, Milton said. Not if she can help it.

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The post In polluted Birmingham community, Trump terminates funding for air monitoring appeared first on alabamareflector.com

Note: The following A.I. based commentary is not part of the original article, reproduced above, but is offered in the hopes that it will promote greater media literacy and critical thinking, by making any potential bias more visible to the reader –Staff Editor.

Political Bias Rating: Left-Leaning

This article exhibits a Left-Leaning political bias through its framing, language, and emphasis on environmental justice, racial disparities, and criticism of the Trump administration’s policy decisions. While it is presented under the banner of a nonprofit, non-partisan outlet, the narrative foregrounds the disproportionate impact on Black communities and casts recent Republican-led actions—particularly the termination of air monitoring and civil rights-related initiatives—in a negative light. It frames these decisions as racially motivated and harmful, aligning with progressive values on environmental equity and systemic injustice, without offering counterarguments or perspectives from the opposing side.

News from the South - Alabama News Feed

Faith Time: Challenges to faith Part I

Published

1 day ago

June 15, 2025

Staff Editor

www.youtube.com – WKRG – 2025-06-15 06:40:01

SUMMARY: Rabbi Steven Silberman of Congregation Ahavas Chesed discussed challenges to faith on Faith Time, emphasizing how global instability prompts deep spiritual questioning, such as “Where is God?” He highlighted the importance of community in Judaism, tracing its roots from Abraham to modern Jewish identity as an extended family. In today’s mobile society, he stressed the need for individuals to find belonging in local Jewish communities. Healthy questioning includes seeking purpose, understanding suffering, and connecting with God. Silberman encouraged engagement through prayer, charitable acts, activism, study, Hebrew language, and ties to Israel as essential ways to navigate and strengthen faith.

We talk about facing challenges to fundamental beliefs.

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News from the South - Alabama News Feed

Scattered summer storms in Alabama for Father's Day.

Published

1 day ago

June 15, 2025

Staff Editor

www.youtube.com – WVTM 13 News – 2025-06-15 06:35:38

SUMMARY: Alabama will experience scattered heavy storms on Father’s Day afternoon, following a cloudy and foggy morning with improving visibility. There’s no severe weather threat, but storms may bring frequent lightning, heavy downpours, and localized flooding, especially in areas like Walker and Winston counties affected by previous heavy rain. Temperatures will be in the mid to upper 80s with hot, steamy conditions. Storm coverage is expected to be more widely scattered than yesterday, but outdoor plans should account for possible rain. Summer storms will continue throughout the week, with decreasing storm activity later, leading to higher heat indices and approaching triple-digit feels-like temperatures by week’s end.