Providers Want More from CMS on Prior Authorization Reform After Proposed Changes

Fierce Healthcare | By Robert King
 
Provider groups say new reforms proposed by the Biden administration to streamline prior authorization are a good start. 
 
But much more needs to be done—including creating gold-card programs that let providers skip prior authorization if they have a high volume of requests, they say. 
 
Several provider and payer groups submitted comments on a proposed rule outlining policy changes for Medicare Advantage (MA) and Part D set to take effect in 2024. One of the biggest changes is to clarify when and how MA plans can use prior authorization, a cost containment tool that requires physicians to get insurer approval before doling out certain items and services but has morphed into a major source of administrative burden for providers.
 
“Physician groups point to delays in prior authorization decisions, resubmission of prior authorization, inconsistent payer payment policies … and prior authorizations for routinely approved items and services as some of the most challenging aspects of prior authorization,” wrote the Medical Group Management Association (MGMA) in comments to the proposed rule that were due Monday.
 
If finalized, the Centers for Medicare & Medicaid Services' (CMS’) rule would mandate that a granted prior authorization approval remains valid for the entire course of treatment for a patient in MA. If an MA plan denies coverage for a request, it must rely on a physician or expert that has expertise in the appropriate field of medicine, CMS added.
 
The agency also proposed prior authorization must be limited to only confirming the presence of a diagnosis.
 
But provider groups say this still doesn’t address the problem that any prior authorization process “inherently delays patient care,” MGMA wrote. “CMS must establish guardrails to prevent high volumes of prior authorization requests by MA plans.”
 
One of these strategies could be gold-carding programs that exempt certain clinicians from prior authorization if they have an approval rating over a period of time. This would help ease the number of requests a physician must face.

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CMS, Insurers Clash Over Whether Medicare Advantage is Going to be Cut in Proposed Rule

Fierce Healthcare | By Robert King
 
Health insurers and the Biden administration are at loggerheads over whether Medicare Advantage (MA) plans will see a pay cut next year, the ramifications of which come amid increased regulatory scrutiny for the popular program.
 
Insurer groups and some politicians charge that the latest 2024 payment rule will wind up being a 2.27% cut to MA plans after considering risk adjustment changes and other factors. The Centers for Medicare & Medicaid Services (CMS) has pushed back, arguing that isn’t true.
 
The debate comes amid increasing scrutiny of MA and after CMS has proposed an overhaul to plan audits to curb overpayments.
 
“We think it is important not to cherry-pick the numbers,” said CMS Administrator Chiquita Brooks-LaSure during a call with reporters last week. “When we look at all the elements, we do see a net positive so an increase of little over 1%.”
 
At issue is the proposed advance notice released earlier this month that details the payments to MA and Part D plans for the 2024 coverage year. The proposed rule lays out the payment policies and changes to MA capitation rates for the upcoming year as well as outlining key changes to risk adjustment. 
 
When the rule was announced Feb. 1, CMS expected a 1.03% increase for plans. The agency came to this number after factoring in a decline in payments when taking in risk adjustment changes. 
 
Since the rule was released, the insurance industry has pushed back that it will actually result in a 2.27% cut to plans if finalized. 
 
The advocacy group Better Medicare Alliance (BMA) said that the rule “would raise costs and cut benefits for 30 million American seniors who rely on Medicare Advantage, a vital part of Medicare,” said BMA President and CEO Mary Beth Donahue in a statement.
 
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Beyond Medicare and Social Security: Cutting Medicaid After the Pandemic Would be Political Madness

STAT News | By Arielle Kane
 
During his State of the Union address, President Biden called out Republican proposals to cut Social Security and Medicare in their quest to reduce federal spending. Republican lawmakers in the chamber protested loudly, knowing these programs are political third rails — too controversial to discuss — and they have been sparring over it ever since.
 
But the president and Democrats in Congress should not miss the opportunity to make Medicaid the third rail. If they want to capitalize on the popularity of the program and protect families’ health care, Medicaid cuts must be off the table because it:

• Covers 91 million Americans, making it the largest source of health care coverage in the country
• Covers 42% of all births
• Pays for 54% of long-term care and covers 6.9 million people ages 65 and older
  Provides coverage to more than 10 million people with disabilities who rely on Medicaid for their health care

Several Republicans have said they want to use the upcoming legislative battle over raising the debt ceiling as an opportunity to cut overall spending, particularly in programs like Medicaid.
 
But politically savvy lawmakers would be wise to remember the health care fights of 2017 — and the results of the 2018 midterm elections that followed — proving that cutting coverage for pregnancy and childbirth, for older adults, and for people with disabilities is a pathway to political collapse. Even in deep red states like South Dakota, Idaho, and Missouri, the electorate has approved Medicaid expansion even when their elected lawmakers opposed it. That’s because Medicaid is a lifesaver for millions of families.
 
That’s never been clearer than over the past three years when Medicaid protected families during an enormous public health crisis. The Covid-19 pandemic upended the economy and tripled the unemployment rate. But largely because of Medicaid, the rate of uninsured reached an all-time low in 2022. That is a stark difference from the last economic upheaval during the Great Recession of 2008-2009, when 9.3 million people lost their jobs and, subsequently, their health insurance. Millions more families now know firsthand how essential Medicaid is for their health and financial well-being and they will not look favorably if their elected representatives decide to cut that lifeline.
 
The Medicaid program faces a daunting challenge in the coming months as the process of checking the eligibility for Medicaid of its 91 million enrollees starts back up again April 1. At the same time, 1 in 4 state Medicaid programs report staff vacancy rates greater than 20%. Millions of people are likely to lose coverage because of administrative hurdles during the eligibility determination process, and they will be hard-pressed to get someone on the phone to assist with their application. It’s political madness to cut Medicaid generally, but particularly so during this herculean lift across all state Medicaid agencies.

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SNFs Retook Higher Hospital Discharge Share Than HHAs In Early 2022

Home Health Care News | By Andrew Donlan
 
After the public health emergency was declared in March of 2020, hospital discharges bottomed out the following month. While they ticked back up in 2021 and 2022, they still remain 25% lower than they were in February of 2020. 
 
And while home health care gained a greater share of post-acute referrals compared to skilled nursing facilities (SNFs) early on in the pandemic, there’s been normalization since then.