On January 17th, CMS announced the pending release of the long-awaited “prior auth rule,” a final rule clarifying requirements and incentives for payers and providers with respect to prior authorization of medical procedures. The rule does not apply to prescription drugs.
Under the new regulation, Medicare Advantage (MA) organizations, state Medicaid and Children’s Health Insurance Program (CHIP) Fee-for-Service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the exchanges must implement and maintain certain Application Program Interfaces (APIs), although there is still some debate over the electronic programing interfaces required to ensure seamless user access.
- Patient Access API. Payers must provide information about prior authorizations to the pool of data available.
- Provider Access API. Payers must link patients to the in-network providers with whom they have a treatment relationship.
- Payer-to Payer API. Payers must make available claims and encounter data — minus details on provider remittances and enrollee cost-sharing information. Plans’ prior authorization metrics will also have to be publicly reported, according to the fact sheet. Fee-for-service plans already make these metrics publicly available.
Importantly, CMS finalized proposals requiring payers to respond to urgent requests within 72 hours and non-urgent requests within a week, rather than the real-time decision-making process included in The Seniors’ Timely Access to Care Act pending in Congress. This is the provision of that bill that was estimated to be the most costly by the Congressional Budget Office. Authors and supporters of the legislation, including U.S. Representatives Larry Bucshon, M.D. (R-IN-08), Mike Kelly (R-PA-16), Suzan DelBene (D-WA-01), Ami Bera, M.D. (D-CA-06), and U.S. Senators Roger Marshal, M.D. (R-KS), Sherrod Brown (D-OH), John Thune (R-SD), and Kyrsten Sinema (I-AZ) released the following statement:
Today’s action by CMS is a major win for seniors and their families. These new regulations will make a big difference in helping seniors access the medical care they are entitled to without unnecessary delays and denials due to prior authorization. The regulations will also enable health care providers to focus on delivering better care rather than wasting hours on the phone with insurance companies. While these regulations could have gone further, they will help bring the antiquated prior authorization system into the 21st century with commonsense changes like a streamlined approval process and increased transparency.”
Now, Congress must act to cement these gains into law by passing the overwhelmingly bipartisan, bicameral Improving Seniors’ Timely Access to Care Act to ensure seniors are getting the care they’re entitled to and reduce hours of unnecessary burden for physical practices and hospitals.
https://bucshon.house.gov/news/documentsingle.aspx?DocumentID=4534
CMS also finalized a new, related measure for Merit-based Incentive Payment System (MIPS) eligible clinicians under the Promoting Interoperability performance category of MIPS as well as for eligible hospitals and critical access hospitals (CAHs) under the Medicare Promoting Interoperability Program.
Other Agency News
Centers for Medicare & Medicaid Services
- CMS Invites Proposals for the 2024 CMS Health Equity Conference, May 29-30
- This year’s theme is “Sustaining Health Equity Through Action.”
- CMS Releases Final Evaluation Report for Next Generation Accountable Care Organization Model
- Doctor and Clinician Utilization (Procedure Volume) Data Now Available on Medicare.gov Compare Tool
- Hip replacement
- Knee replacement
- Spinal fusion
- Cataract surgery
- Colonoscopy
- Hernia repair – groin (open)
- Hernia repair (minimally invasive)
- Mastectomy
- Coronary artery bypass graft (CABG)
- Pacemaker insertion or repair
- Coronary angioplasty and stenting
- Prostate resection
- More information
Department of Health & Human Services
- No additional meetings or regulatory updates.
FDA
- CDRH published a mandatory report to Congress on the Device Pilot Projects overseen by the National Evaluation System for health Technology (NEST) – The report includes information on (1) how such pilot projects are being implemented through a contract, cooperative agreement, grant, or other appropriate agreement; (2) the number of manufacturers that have agreed to participate in such projects; (3) the data sources used to conduct such pilot projects; (4) the devices or device categories involved in the pilot projects; (5) the number of patients involved in such projects; and (6) the findings of each project in relation to the device’s safety, including adverse events, malfunctions, and other safety information.
- Registration is open for the International Medical Device Regulators Forum, March 11-15 in Washington, DC
- CDRH Publishes Annual Report for 2023
- This week also saw renewed pressure on the administration to ban menthol from tobacco products.
Hill Highlights
- Congress passed another stop-gap spending bill, funding the federal government and all health care extenders through March 8th. Extenders included in the package include,Community Health Centers, teaching hospitals and diabetes programs, and a delay of Medicaid cuts to disproportionate share hospitals as well as Medicare’s Geographic Work Index Floor and some provisions of the Pandemic and All-Hazards Preparedness Act (PAHPA). However, the patch failed to address physician pay cuts that went into effect on January 1. CMS had the flexibility to refrain from processing claims net of the required cuts for a period of 2 weeks, so as to avoid having to reprocess claims if Congress updated the conversion factor retroactively. However, with the grace period having expired, and in light of Congress’ failure to take action, the 3.37% will go into effect. Although the conversion factor only impacts fee-for-service (FFS) Medicare, rates for Medicare Advantage (MA) plans are based on FFS. Interested parties will be paying close attention to the publication of future MA rules to understand the full impact.
- Senator Bill Cassidy, M.D. (R-LA), ranking member of the Senate Health, Education, Labor and Pensions (HELP) Committee, is seeking information from CVS and Walgreens, major contract pharmacies as part of his ongoing investigation into how health care entities use and generate revenue from the 340B Drug Pricing Program.
