Medical Necessity

Prior authorization in Medicare Advantage remains in the policy spotlight as 2024 regulations take effect

Healthcare policymakers and stakeholders continue to mull the need for guardrails to ensure optimal customer service among Medicare Advantage (MA) health plans. The American Hospital Association wrote a Nov. 20 letter to CMS stating that MA plans are looking to skirt policies designed to ensure straightforward coverage of essential healthcare services. These policies, finalized earlier…

Nick Hut December 1, 2023

Report quantifies the financial impact of certain health plan business practices on providers

As hospitals seek to regain their financial footing coming out of the pandemic, they may find themselves stymied by commercial payer policies, according to a new report. “It’s true that commercial payers might generate more net revenue than public payers on a per-case basis,” Crowe states in a report it recently published. “But at what…

Nick Hut June 2, 2023

News Briefs: Medicare’s proposed FY24 update to inpatient payments falls short, hospitals say

Hospitals are less than pleased with Medicare’s proposed FY24 payment increase for inpatient care. In regulations released April 10, the net inpatient payment update is 2.8% after factoring in a mandatory productivity adjustment of -0.2 percentage points. As usual, the update would be reduced for any hospital that does not fulfill quality-reporting requirements or qualify…

Nick Hut April 28, 2023

CMS and other stakeholders take steps to improve prior authorization in Medicare Advantage and beyond

Several recent developments point to an industrywide effort to ease the burden of prior authorization. Most notably, CMS on April 5 finalized a rule that includes provisions designed to improve prior authorization in Medicare Advantage (MA) starting with the 2024 plan year. The rule addresses a few aspects of prior authorization, among them the way…

Nick Hut April 6, 2023

New federal rule aims to eventually ease prior authorization processes

CMS is seeking to improve the prior authorization process in government programs such as Medicare Advantage (MA) and Medicaid, although the core provisions would not begin until 2026. The agency this week updated a Trump administration proposed rule with new proposals to “improve patient and provider access to health information and streamline processes related to prior authorization…

Nick Hut December 9, 2022

CMS says EMTALA covers situations in which terminating a pregnancy is medically necessary

Even in situations that don’t qualify as life-threatening, the Biden administration says patients have the legal right to receive any type of stabilization measure at the discretion of their physician.

Nick Hut July 13, 2022

Some Medicare payments to hospitals for bariatric surgery may be inappropriate, OIG finds

Medicare could have saved nearly $48 million in bariatric surgery payments to hospitals during an 18-month period if coverage rules and guidance were better implemented at the contractor level, according to the HHS Office of Inspector General.

Nick Hut May 17, 2022

OIG calls out issues with denials of payment and services in Medicare Advantage

Medicare Advantage processes related to prior authorization hamper beneficiaries’ access to medically necessary care, according to a new report from the HHS Office of Inspector General.

Nick Hut April 29, 2022

CMS leaders explain final plans to restrict Medicare coverage of new Alzheimer’s drug

CMS mostly finalized previously proposed criteria for coverage of Aduhelm, which has been promoted as the first drug to treat the underlying pathology of Alzheimer’s disease.

Nick Hut April 16, 2022

Medicare coverage updates include revised criteria for lung cancer screening and a code for a newly approved COVID-19 treatment

CMS in February amended its coverage requirements for lung cancer screening and issued a code for a new COVID-19 treatment.

Nick Hut March 5, 2022
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-leaderboard' ); } );