CMS President, Surgeon General promotes possible changes in pre-licensing

Leaders seek physician feedback on rule proposals for electronic records and Medicare Advantage plans.

Federal health care leaders say they are committed to helping physicians, patients, and health insurers by improving the Medicare pre-authorization process.

On January 17, the Center for Medicare and Medicaid Services Directors Chiquita Brooks Lashore And General surgeon in the United States Vice Adm. Vivek H. Murthy, MD, MBA, held a hearing with healthcare stakeholders. A conference call with the media followed to explain the changes under consideration:

Simplify the pre-authorization process for doctors and patients.

Create new standards for electronic attachments and signatures related to health care documents.

Strengthening the rules for people who are enrolled in or seeking coverage from Medicare Advantage plans or Medicare prescription drug plans.

“These proposed measures will greatly simplify the pre-licensing process for physicians, improve the healthcare experience for the people we serve and ensure they can access the care they need,” said Brooks Lashore.

Murthy cited his own consultation in May 2022, “Tackling health worker burnout,” And how to add paperwork burdens with prior authorization to it.

“Today it is difficult to find a doctor or patient who has not been adversely affected by prior authorization,” said Murthy. “Physicians should not have to spend hours every day fighting for their patients to access evidence-based care and treatment. And patients should not have to deal with the uncertainty of not knowing whether or not they can get the care they need and deserve.

“Our goal is to ensure an efficient, transparent and effective prior authorization policy to ensure accountability and ultimately eliminate delays in care and damages,” he said.

Other speakers include Meena Sechamani, MD, PhD, CMS Deputy Director and Director of the Center for Medicare, and Mary Green, MD, MPH, MBA, CMS Director of the Office of Burden Reduction and Health Informatics.

previous endorsements

in that Advertising In December 2022, CMS noted that “patients, providers, and payers alike have experienced a burden.” Previous licenses contributed to physician fatigue and posed a health risk to patients if the operation caused delays in receiving healthcare.

the It will require a new base:

  • Reasons for denial. Payers will provide specific reasons for denying prior authorization applications to improve communication and facilitate successful re-application, if necessary.
  • Faster Turnaround: A pre-authorization decision will be required within 72 hours for urgent or urgent requests and seven days for standard or non-urgent requests. CMS said its leaders want to comment on shorter lead times, such as 48 hours for urgent requests and five calendar days for non-urgent requests.
  • Prior authorization metrics. Payers will publicly report their numbers online each year.

The proposed rules generally apply to Medicare Advantage organizations, Medicaid Children’s Health Insurance Program (CHIP) agencies, Medicaid managed plans, CHIP managed care entities, and qualified health care plan issuers on federally facilitated exchanges. The rules are posted online and the CMS has an extension An open comment period It is until March 13th.

If finalized, the new policies for pre-licensing will go into effect on January 1, 2026.

health care enclosures

separately but linked SuggestionCMS is considering new standards for “health care facility” transactions, such as medical charts, x-rays, and provider notes for physician referrals, office visits or telemedicine. On the call, Brooks-LaSure noted that health care physicians currently use fax machines and paper mail to send medical charts, X-rays, or notes — and may “spend hours figuring out what documents are required for prior authorization.”

The Health Insurance Portability and Accountability Act (HIPAA) and the Affordable Care Act (ACA) require the US Department of Health and Human Services to adopt the Health Care Claim Facility Standard. The new standards will apply to entities subject to HIPAA, including health plans, healthcare clearing houses, and healthcare providers.

The proposed rule a Fact statement It is published on the Internet and the content management system is Solicit comments On proposals through March 22nd.

Medicare advantage

Prior authorization is also part of a Third proposed rule That would change Medicare Advantage Plans Regulations. The rule will:

MA plans require the development and use of coverage standards and policies so that enrollees in MA have the same access to essential care that they would have in traditional Medicare.

Simplify pre-authorizations by requiring pre-authorizations to remain valid for the associate’s full course of treatment.

Review regulations for Medicare Advantage plan marketing to avoid confusion and pressure on enrollees.

Add behavioral health services through clinical psychologists, licensed clinical social workers, and prescribers for opioid use disorder.

Comments on new regulations February 13th.

how much money?

CMS estimates that the new pre-licensing policies will create efficiencies that save $15 billion over 10 years for physician practices and hospitals.

By using a fully electronic system for advance authorizations, the health care industry could save an estimated $454 million annually, according to CMS, which cited a 2019 report by the Council on Affordable and Quality Health Care. When standardizing electronic health records, attachments, and signatures on claims, the health care industry could save an estimated $374 million annually, with a total savings of $828 million annually for prior authorizations and claims.

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