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Tag: Prior Authorization


David Chandler

News

CMS piles on prior auth requirements 

February 7, 2024Liz Beaulieu, Editor

YARMOUTH, Maine – A rule finalized in January is CMS’s latest bid to fine-tune the prior authorization process for Medicare Advantage plans and other payers to increase efficiency and transparency.  The agency in January finalized a rule requiring MA plans and other payers like Medicaid and Medicaid managed care to send prior authorization decisions within 72 hours for urgent requests and seven calendar days for standard requests. For some payers, CMS says, this cuts the current...

Andrea Stark, David Chandler, Medicare Advantage, Prior Authorization


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In brief: Prior auth burden, VGM Forbin president, JANZ acquisition

January 19, 2024HME News Staff

WASHINGTON – CMS has finalized a rule that sets requirements for Medicare Advantage organizations and other programs to improve the electronic exchange of health information and prior authorization processes and reduce burden on patients, providers and payers.  The agency estimates its Interoperability and Prior Authorization Final Rule (CMS-0057-F) will result in $15 billion in estimated savings over 10 years.  “When a doctor says a patient needs a procedure, it is essential...

Complex Rehab Technology (CRT), JANZ, Masimo, Mullaney's Medical Supply, Prior Authorization, United Spinal Association, VGM Forbin


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CMS expects big savings from prior auth rule

January 18, 2024HME News Staff

WASHINGTON – CMS has finalized a rule that sets requirements for Medicare Advantage organizations and other programs to improve the electronic exchange of health information and prior authorization processes and reduce burden on patients, providers and payers.  The agency estimates its Interoperability and Prior Authorization Final Rule (CMS-0057-F) will result in $15 billion in estimated savings over 10 years.  “When a doctor says a patient needs a procedure, it is essential...

DME Medicare Administrative Contractor (DME MAC), Prior Authorization


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newspoll

News

Slight majority opposes prior auths, according to poll

September 15, 2023Theresa Flaherty, Managing Editor

YARMOUTH, Maine – Prior authorizations have their uses, but they also create a heavy burden with no guarantee of payment, say 58% of respondents to a recent HME Newspoll.  “Prior authorization is fine if the insurance plan honors their end of the agreement,” wrote one respondent. “To do all the work to obtain the PA only to receive a denial is very frustrating. Even more frustrating is to have the plan tell you that prior authorization is not a guarantee of payment.”  Prior...

Prior Authorization


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On the Editor's Desk

Swords and sticks

September 15, 2023Liz Beaulieu, Editor

YARMOUTH, Maine – It was big news when UnitedHealthcare announced it would reduce the number of product codes requiring prior authorizations. Cigna soon followed suit and then Blue Cross Blue Shield of Michigan and others. While it was big news, it wasn’t surprising.  The American Medical Association (AMA) has been on a fierce campaign to reduce prior authorizations. On its website, the AMA characterizes it this way: “Prior authorization is a health plan cost-control process...

Prior Authorization


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Also Noted

Cigna updates prior auths list

September 7, 2023HME News Staff

BLOOMFIELD, Conn. – Cigna has removed prior authorization requirements for nearly 25% of medical services. With the removal of these 600-plus codes, the insurer has now removed prior authorization requirements on more than 1,100 medical services since 2020. "Our goal is to help keep patients safe, improve health outcomes, and make care more affordable, and this important step will enable us to do that while removing administrative burdens on the health care system," said David Brailer, MD,...

Cigna, Prior Authorization


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Laura Williard

News

Stakeholders seek details on UHC plan to eliminate some prior auths

September 1, 2023Theresa Flaherty, Managing Editor

WASHINGTON – UnitedHealthcare’s plan to reduce prior authorizations was met with skepticism by industry stakeholders who say it’s more likely a public relations move in response to increased government scrutiny.  In August, UnitedHealthcare said it would begin a two-phased approach to eliminating prior authorizations for many product codes starting Sept. 1, 2023. That’s after the Senate Homeland Security and Government Affairs Committee in May held a hearing on...

AAHomecare, Prior Authorization, UnitedHealthcare, VGM & Associates


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In brief: Lincare lawsuit, UnitedHealthcare prior auths, O&P finalists 

August 23, 2023HME News Staff

CLEARWATER, Fla. - Lincare has filed a lawsuit in Connecticut district court against former CEO Crispin Teufel, who plans to join competitor AdaptHealth on Sept. 1, for breach of contract, breach of duty of loyalty and misappropriation of trade secrets.  Lincare seeks a temporary restraining order, preliminary and permanent injunctive relief, damages and attorney fees.  “Since defendant’s resignation, plaintiffs have uncovered evidence demonstrating that defendant used...

Crispin Teufel, Lincare, Orthotics & Prosthetics, Prior Authorization, UnitedHealthcare


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UnitedHealthcare drops certain prior authorizations 

August 21, 2023HME News Staff

EDINA, Minn. – UnitedHealthcare says it will begin a two-phased approach to eliminating the prior authorization requirement for many procedure codes starting Sept. 1, 2023, to help reduce the administrative burden on health care professionals and their staff.  This move will reduce the payer’s overall prior authorization volume by nearly 20%.  “This is part of our comprehensive effort to simplify the health care experience for our members and network health care...

Billing, Prior Authorization, UnitedHealthcare


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Also Noted

VGM seeks to streamline MA complaint process 

June 26, 2023HME News Staff

WATERLOO, Iowa – VGM & Associates encourages providers to supply the Office for Program Operations and Local Enforcement at CMS with examples of Medicare Advantage organizations denying prior authorizations and claims for several important categories of DME. “We understand the urgency surrounding these issues and have been talking with them about the best process to resolve them,” VGM stated in a recent bulletin. “In addition to those efforts, several of our members have asked...

Complaint, Medicare Advantage, Prior Authorization, VGM & Associates


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