Congress Debates Bill to Automate Prior Authorization in Medicare Advantage Plans

Recently the House of Representatives’ Small Business Committee convened for a hearing on utilization management and barriers to care in small medical practices. In particular this hearing focused on the application of prior authorization within Medicare Advantage (MA) plans and the associated challenges faced by patients and providers of services due to prior authorization requirements.…

OIG Finds Medicare Part D Still Spending Millions for Hospice Drugs

Over recent years the Department of Health & Human Services Office of the Inspector General (OIG) and others have conducted analyses of spending outside of hospice while patients are on service and determined that Medicare may be paying separately for care (including prescription drugs under Part D) that should be the responsibility of the hospice. …

CMS Announces Start Date for Review Choice Demonstration

The Centers for Medicare & Medicaid Services (CMS) posted long-awaited information this morning about the next steps for its Review Choice Demonstration, which will begin in Illinois on June 1, 2019. As reported previously in NAHC Report, CMS announced its plans to modify the Pre-Claim Review Demonstration, now called Review Choice Demonstration, on May 30.…

Review Choice Demonstration to Begin Soon

The Review Choice Demonstration (RCD) project has cleared the Office of Management and Budget, allowing the Centers for Medicare and Medicaid Services (CMS) to begin implementing the Demonstration project. On May 30, 2018, CMS announced it plans to revise the Pre-Claim Review Demonstration project, now referred to the RCD, following the pause of the Pre-Claim…

CMS Chief: Prior Authorization Needed to Fight “Fraud and Abuse”

CMS Administrator Seema Verma complained that the federal government needs more legal authority to conduct Medicare prior authorization reviews she says work well in the private sector during a speech to the America’s Health Insurance Plans 2018 National Conference on Medicare on Tuesday, October 16. Interestingly, according to a report from Inside Health Policy, Barbara…

Florida Members of Congress Question CMS about Prior Authorization Program

In response to the Review Choice Demonstration (RCD) program, as proposed by the Centers for Medicare and Medicaid Services (CMS), members of the Florida Congressional Delegation have submitted a letter to CMS outlining their concerns with the program. The RCD program, a slightly modified version of 2016’s Pre-Claim Review (PCR) demonstration program, was proposed as…

GAO Calls for CMS to Resume Prior Authorization Experiment

A new report from the Government Accountability Office (GAO) calls on the Centers for Medicare & Medicaid Services (CMS) to resume or extend prior authorization experiments that have either been halted or are due to end soon. CMS began using prior authorization programs in September 2012 to ensure Medicare coverage and payment rules were met…

Administration’s Proposed FY2019 Budget Ups Ante on Medicare/Medicaid Program Integrity

The President’s Fiscal Year 2019 budget release on Monday includes a slate of Medicare and Medicaid program integrity proposals certain to affect the home health care community. Centers for Medicare & Medicaid Services (CMS) actuaries project that every new dollar spent combating fraud results in $2 saved, and budget documents point to a return on…