CMS Finalizes Interoperability And Prior Authorization Rule
The Centers for Medicare and Medicaid Services (CMS) finalized a sweeping interoperability rule today that also sets much stricter timelines for medical service prior authorizations. The rule was published some time ago and garnered a great deal of comments. The rule takes effect in January 2026 and requires 7 day standard and 72 hour expedited prior authorization turnaround times (federal Exchange plans excepted). Plans now have until 2027 to have APIs to allow providers to submit authorizations electronically. A national format exists for retail prescription drugs, but not a consistent one for medical service requests yet. The final specifications for medical services will tie to the Davinci Project, which will use the new FHIR standard. But plans will be able to use X12 formats as well. The rule applies to Medicare Advantage (MA), Medicaid, children’s coverage, and the federal Exchanges.
The finalization of this rule follows the 2024 MA and Part D rule going into effect, which substantially restricts MA from using outside evidence-based clinical criteria in prior-authorizations. Plans will be subject to immediate audit on these new rules.
Additional articles here:
https://www.healthcaredive.com/news/cms-final-prior-authorization-rule-payer-deadline/704721/
https://www.medpagetoday.com/practicemanagement/reimbursement/108299
https://thehill.com/policy/healthcare/4413508-biden-rule-health-insurer-prior-authorization/
(Some articles may require a subscription.)
#priorauthorization #managedcare #healthcare #fhir #interoperability
Distressed Hospitals Growing And Need Help
A good article on the growing number of distressed hospitals and approaches to investing in and stabilizing them for the benefit of communities.
(Article may require a subscription.)
#hospitals #ruralhealthcare
Supreme Court Could Reduce Regulatory Discretion
While there is no decision yet, there is strong speculation that the Supreme Court could massively rein in regulatory discretion in a ruling this term. If there is not an outright overturning of an earlier precedent known as Chevron, parameters will be set on how far a regulator can go to interpret and implement a law. The wild cards may be Chief Justice Roberts and Justice Barrett. Many worry that an outright overturning of Chevron could complicate implementations of laws (including the Inflation Reduction Act’s Medicare drug price negotiations), while others complain that regulators have too much power and do not abide by the intent of laws.
Additional article here: https://insidehealthpolicy.com/daily-news/justices-divided-chevron-arguments-kagan-points-fda-ai
(Some articles may require a subscription.)
#regulations #healthcare #supremecourt
Growing Number of Disabled Seniors Will Challenge System
Kaiser Health News speaks to the growing number of disabled seniors and how the healthcare system is not ready to serve them. A new disability rule will address some of the discrimination.
As well, here are a Kaiser Family Foundation press release and analysis of the characteristics working adults with disabilities living in the community: https://www.kff.org/medicaid/issue-brief/working-age-adults-with-disabilities-living-in-the-community/ and https://www.kff.org/medicaid/press-release/what-2024-could-bring-for-working-age-adults-with-disabilities/ .
#medicare #disabled
JAMA Study Shows Healthcare Costs Taking Bite Out Of Workers’ Paychecks
Rising healthcare premiums and costs are taking a bite out of workers’ paychecks. One great stat: In 1988, health care premiums on average accounted for a little less than 8% of a worker’s total compensation. By 2019, that had increased to an average of almost 18%. Because healthcare premiums are not income-based in the employer group sector, this hits lower-paid workers the most.
Additional article here: https://www.healthcaredive.com/news/employer-sponsored-health-insurance-premium-growth-wage-stagnation-jama-network-open/704758/
#healthcare #coverage #costs
Drug Price Hikes Occurring As Expected in January
Drug companies are increasing prices as they often do in January. So far, there have been about 600 price hikes. Increases have not been at record levels (10% plus) but have averaged about 5% so far this year (in line with the last several years). Reported rebate percentages are about 52%.
#drugpricing #ira
— Marc S. Ryan
