Medical Necessity

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

Healthcare stakeholders are invited to contribute suggestions for improving prior authorization

A two-month comment period is available for healthcare stakeholders to suggest electronic standards that would make the prior authorization process more efficient.

Nick Hut January 24, 2022

News Briefs: Federal vaccination requirements finalized for hospitals and most other healthcare settings

If a hospital’s staff aren’t fully vaccinated by Jan. 4, the organization will be deemed noncompliant with Medicare and Medicaid regulations, according to a new federal rule.

Nick Hut November 30, 2021

CMS cancels regulations that would ensure coverage of breakthrough medical devices, but new legislation could fill the void

Citing patient safety concerns among other issues, CMS formally canceled a Trump administration rule that would have required Medicare to cover breakthrough medical devices.

Nick Hut November 20, 2021

AMA releases 2022 CPT code set with new options that apply to COVID-19 vaccination, digital care services and more

The new set features more than 400 CPT code changes from 2021.

Nick Hut September 10, 2021
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