Prior Authorization
OIG Releases Report on Medicaid Managed Care Prior Authorizations
On July 19, the Office of Inspector General (OIG) at the US Department of Health and Human Services released a report detailing concerns about the prior authorization processes used by Medicaid Managed Care Organizations (MCOs). In the report, OIG found that: On average, the reviewed MCOs denied one out of every eight prior authorization requests […]
Read MoreCMS Issues Proposals to Improve Exchange of Health Care Data and Prior Authorizations
The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to improve patient and provider access to health information and streamline processes related to prior authorization for medical items and services. CMS proposes to require certain payers to implement an electronic prior authorization process, shorten the time frames for certain payers to respond […]
Read MoreSenate Bill Aims to Speed Process of Prior Authorization for Medicare Advantage
Bipartisan legislation introduced in the United States Senate would ease, standardize, and speed the process of prior authorization in Medicare Advantage plans. The Improving Seniors’ Timely Access to Care Act, would automate the prior authorization process in Medicare Advantage plans through electronic submission of prior authorization requests with real-time determinations by the MA plans. The legislation […]
Read MoreCMS Proposes New Rules to Address Prior Authorization and Reduce Burden on Patients and Providers
The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule on Thursday, December 10, intended to improve the electronic exchange of health care data among payers, providers, and patients, and streamline processes related to prior authorization to reduce burden on providers and patients. According to CMS, the proposed rule aims to improve data sharing […]
Read MoreCongress Debates Bill to Automate Prior Authorization in Medicare Advantage Plans
Recently the House of Representatives’ Small Business Committee convened for a hearing on utilization management and barriers to care in small medical practices. In particular this hearing focused on the application of prior authorization within Medicare Advantage (MA) plans and the associated challenges faced by patients and providers of services due to prior authorization requirements. […]
Read MoreOIG Finds Medicare Part D Still Spending Millions for Hospice Drugs
Over recent years the Department of Health & Human Services Office of the Inspector General (OIG) and others have conducted analyses of spending outside of hospice while patients are on service and determined that Medicare may be paying separately for care (including prescription drugs under Part D) that should be the responsibility of the hospice. […]
Read MoreCMS Announces Start Date for Review Choice Demonstration
The Centers for Medicare & Medicaid Services (CMS) posted long-awaited information this morning about the next steps for its Review Choice Demonstration, which will begin in Illinois on June 1, 2019. As reported previously in NAHC Report, CMS announced its plans to modify the Pre-Claim Review Demonstration, now called Review Choice Demonstration, on May 30. […]
Read MoreReview Choice Demonstration to Begin Soon
The Review Choice Demonstration (RCD) project has cleared the Office of Management and Budget, allowing the Centers for Medicare and Medicaid Services (CMS) to begin implementing the Demonstration project. On May 30, 2018, CMS announced it plans to revise the Pre-Claim Review Demonstration project, now referred to the RCD, following the pause of the Pre-Claim […]
Read MoreCMS Chief: Prior Authorization Needed to Fight “Fraud and Abuse”
CMS Administrator Seema Verma complained that the federal government needs more legal authority to conduct Medicare prior authorization reviews she says work well in the private sector during a speech to the America’s Health Insurance Plans 2018 National Conference on Medicare on Tuesday, October 16. Interestingly, according to a report from Inside Health Policy, Barbara […]
Read MoreFlorida Members of Congress Question CMS about Prior Authorization Program
In response to the Review Choice Demonstration (RCD) program, as proposed by the Centers for Medicare and Medicaid Services (CMS), members of the Florida Congressional Delegation have submitted a letter to CMS outlining their concerns with the program. The RCD program, a slightly modified version of 2016’s Pre-Claim Review (PCR) demonstration program, was proposed as […]
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