The CMS Interoperability and Prior Authorization Rules
With recent CMS mandates and state-level reforms, the healthcare industry faces a pivotal moment to improve prior authorization processes, ensuring timely access to care and integrating health equity considerations....more
On April 5, 2023, the Centers for Medicare & Medicaid Services (CMS) published an expansive final rule amending Medicare Advantage (MA) regulations related to, among other things, coverage criteria and prior authorization....more
When stakeholders think about prior authorization in the Medicare program, they usually focus on its use in Medicare Advantage (MA), and not how it is used in traditional Medicare. In fact, a few weeks ago, the Centers for...more
On 17 January 2024, the Centers for Medicare & Medicaid Services (CMS) released a final rule outlining new interoperability and prior authorization requirements for certain payors (Final Rule). With the adoption of the Final...more
I, JEFFREY DAVIS, RETROACTIVELY DECLARE THE MONTH OF JANUARY IN THE YEAR 2024 TO BE KNOWN AS “MEDICARE ADVANTAGE MONTH.” Obviously, I don’t have the power to do that, but the health policy community did see a lot of...more
On January 18, 2024, CMS released a pre-publication version of a final rule (the Final Rule) that will require Medicare Advantage organizations (MA or Part C), Medicaid and the Children’s Health Insurance Program (CHIP)...more
Last week CMS issued its final rule “CMS Interoperability and Prior Authorization” (CMS-0057-F), unchanged from its proposed rule in 2022, which addresses prior authorizations. Prior authorization, a “utilization management”...more
Prior authorizations, one of health insurers’ many “utilization management” techniques, is a hot topic amongst practicing physicians, patients, and regulators, to name a few. The prior-authorization process requires a health...more
In the Office of the Inspector General's latest report released in April of 2022, the denials of some prior authorization requests by Medicare Advantage Organizations (MAOs) raise concerns about beneficiary access to...more