When it comes to prior authorization and utilization management, the regulatory landscape is always changing! Here’s a list of five places that make it easy for me to stay up-to-date on the latest policy and regulations.
Becker’s Payer Issues
Becker’s Review’s Payer Issues newsletter helps me to stay on top of recent federal regulatory initiatives, the actions of influential health plans and vendors, high-profile legal cases, and the latest pharmacy attention.
Did you see: Representatives unveil Medicare Advantage gold-card legislation
Two US representatives have introduced a gold-card bill to exempt qualifying providers from Medicare Advantage prior authorization requirements.
Did you know: Cohere’s approach to intelligent prior authorization provides an alternative to gold carding called green lighting, which lightens the load for physicians without shutting off the system entirely. My colleague, Tracy Zheng, PhD, has more to say about green lighting here.
Politico’s Future Pulse
Politico is a well-known publication for the latest global and national political and public policy news for an American audience. Their Future Pulse newsletter collates stories about the new ideas and innovations shaping healthcare.
Did you see: Congress’ prior authorization power play
More than 230 representatives and 61 senators wrote to Health and Human Services and CMS, asking them to make changes to a proposed rule that would require health insurance companies to modernize authorization processes.
Did you know: Cohere digitizes and streamlines the manual prior authorization process, delivering instantaneous decisions for many requests. Learn three ways you can improve prior authorization decisioning with AI.
Healthcare Dive
Healthcare Dive covers the latest trends in health IT, policy and regulation, insurance, digital health, payer-provider partnerships, and value-based care. I love how they sort stories by their audience! It makes it easy to go right to the government articles when I am looking for the latest information on prior authorization regulations.
Did you see: UnitedHealth unit sued by Labor Department over systematic claims denials
The government alleges UMR improperly denied thousands of ER and drug screening claims submitted between August 2015 and 2018. It is calling for UMR to re-adjudicate claims denied since 2015 and update its claims process.
Did you know: Intelligent prior authorization digitizes the process, using interfaces like portals and EHR integration to increase transparency between health plans and their provider partners. Learn how the high-speed intelligent prior authorization information pathway brings longitudinal context to individual prior authorization transactions.
Modern Healthcare
Modern Healthcare publishes healthcare business and policy news, and research, covering healthcare events and trends.
Did you see: CMS prior authorization data rules in conflict, AHA, AMA, insurers say
A coalition of healthcare industry groups wrote CMS, voicing concerns about conflicting rules governing patient data exchanges during prior authorization reviews. Unless reconciled, these rules may create confusion and higher costs.
Did you know: Intelligent prior authorization allows health plans to take regulatory compliance to the next level. It goes beyond simply digitizing fax intake and automating decisioning to meet shortened turnaround time requirements. Health plans can leverage isolated requests to enable collaborative management of the entire patient journey, and can promote earlier care interventions by applying clinical intelligence to transactional data. Discover the secret to reducing physician burden in prior authorization.
America’s Health Insurance Plans (AHIP)
As a nonprofit organization, AHIP is committed to promoting market-based solutions and public-private partnerships that make health care better and coverage more affordable and accessible for everyone. Their resource hub includes great policy resources and research.
Did you see: Impact of Federal Prior Authorization Requirements on States
New federal prior authorization rules create opportunities for states to align with federal requirements, promote transparency, and improve care.
Did you know: Health plans can drive impact by creating two-way communication around prior authorization requirements and decisioning—by digitizing prior authorization intake across all channels. Adopting a provider portal reduces provider burden with immediate determination notifications and instant lookup capabilities to determine if a prior authorization is required. Here’s six questions to kickstart your CMS compliance conversations.
Curious how intelligent prior authorization can help your plan comply with recent federal and state regulations? Download this white paper to learn more.
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About the Author: Brian Covino, M.D., FAAOS
