Prior Authorization

Medicare Advantage final rule addresses competition and marketing practices

April 8, 2024 - CMS has finalized policies to promote competition in Medicare Advantage and Part D plans, boost access to behavioral healthcare services, and reduce deceptive marketing practices. The Contract Year (CY) 2025 Medicare Advantage and Part D final rule included guardrails about plan compensation to agents and brokers who help beneficiaries navigate...

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Utilization Restrictions on Medicare Part D Drugs Increased, Study Finds

by Victoria Bailey

Utilization restrictions on Medicare Part D drugs, including prior authorization and formulary restrictions, increased over time between 2011 and 2020, according to a Health Affairs study. Pharmacy...

With Proper Use, Artificial Intelligence Improves Health Plan Operations

by Victoria Bailey

While artificial intelligence is far from a new concept, the healthcare industry has recently latched on to the technology, leading to increased adoption across many sectors. Artificial intelligence has the potential to lower healthcare...

Care Access, Coverage Value Similar in Medicare Advantage and Medicare

by Victoria Bailey

Coverage and care experiences were generally similar for Medicare Advantage and traditional Medicare beneficiaries, but instances of care delays and health assessments differed, a survey from the...

Overcoming Tech Barriers to Achieve Prior Authorization Transparency

by Victoria Bailey

Prior authorization has posed problems for nearly all healthcare stakeholders. The CMS Interoperability and Prior Authorization Final Rule aims to streamline the utilization management process and improve data-sharing between payers,...

HHS Seeks Stakeholder Input to Improve Medicare Advantage Transparency

by Victoria Bailey

HHS has issued a request for information (RFI) to help improve data-sharing and transparency in the Medicare Advantage. Over half of all Medicare beneficiaries are enrolled in Medicare Advantage,...

CMS Finalizes Payer Requirements to Streamline Prior Authorization

by Victoria Bailey

CMS has finalized requirements for payers to streamline the prior authorization process and improve the electronic exchange of health information to help limit patient care disruptions. The CMS...

What Utilization Management Strategies Do Payers Use to Lower Costs?

by Victoria Bailey

As healthcare spending rises in the United States, stakeholders are constantly working to address the drivers of high costs. The overutilization of healthcare services—including the provision of low- or no-value care—not only...

Key Regulations and Policies That Will Impact Payers in 2024

by Victoria Bailey

As healthcare stakeholders and the federal government work to make healthcare more accessible and affordable for consumers, CMS and HHS are frequently introducing and finalizing new rules and regulations. There were a couple of key...

Lawmakers Urge CMS to Improve Data Collection in Medicare Advantage

by Victoria Bailey

Four United States Senators have called on CMS to improve data collection and reporting in the Medicare Advantage program to help regulators understand how plan design impacts care quality, cost, and...

Blue Cross Blue Shield of MA Eliminates More Prior Authorizations

by Kelsey Waddill

Blue Cross Blue Shield of Massachusetts (“Blue Cross”) joined other payers in eradicating prior authorizations for certain services as part of an effort to accelerate members’ access...

KLAS: Epic’s Payer Platform Generates High User Satisfaction

by Victoria Bailey

Healthcare organizations using Epic’s payer platform are satisfied with the product’s performance, including its ability to deliver meaningful information without disrupting workflows,...

Cigna Removes Prior Authorization for 25% of Medical Services

by Victoria Bailey

Cigna Healthcare is removing prior authorization requirements for nearly 25 percent of medical services, facilitating access to care for members. The Cigna Group’s health benefits provider...

How Payers Are Reducing Prior Authorizations, Limiting Care Disruptions

by Victoria Bailey

Although prior authorization aims to control costs and limit unnecessary medical procedures, healthcare stakeholders have continued to raise concerns that the process creates substantial administrative...

AHIP, BCBSA Voice Concerns About Proposed Prior Authorization Rule

by Kelsey Waddill

AHIP joined the American Hospital Association (AHA), American Medical Association (AMA), and Blue Cross Blue Shield Association (BCBSA) in opposing the prior authorization reformation efforts from CMS...

Healthcare Organizations Oppose UHC’s GI Prior Authorization Program

by Victoria Bailey

More than 170 healthcare organizations have urged UnitedHealthcare not to implement its gastrointestinal (GI) endoscopy prior authorization program, stating that it will hurt patients and limit access...

Medicare Advantage Final Rule Addresses Prior Authorization, Health Equity

by Victoria Bailey

CMS has finalized a Medicare Advantage rule that aims to increase marketing oversight, streamline prior authorization requirements, and improve access to affordable prescription drugs. “The...

What the Prior Authorization Proposed Rule Means for Payers

by Victoria Bailey

The CMS Advancing Interoperability and Improving Prior Authorization Processes proposed rule introduces new requirements for healthcare payers that aim to enhance patient data sharing and streamline...

Medicare Advantage Plans Rejected 2M Prior Authorization Requests in 2021

by Victoria Bailey

Medicare Advantage plans denied 2 million prior authorization requests in 2021 and just 11 percent of those requests were appealed, according to an issue brief from the Kaiser Family Foundation...

Payer, Provider Orgs React to Prior Authorization Proposed Rule

by Kelsey Waddill

Payer and provider organizations are responding positively to the CMS proposed rule that would change the prior authorization process to better support electronic prior authorization. “CMS is...

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