Health Plan Weekly

The rule that CMS finalized last month regarding prior authorization (PA) should help streamline the increasingly scrutinized process and lead to faster decisions, according to panelists who spoke during a KFF webinar on Feb. 22. However, they noted that regulation did not apply to employer-sponsored plans or state-based exchange plans and did not address how PA decisions are made and the clinical criteria plans use in determining which procedures are subject to PA. 

Troyen Brennan, M.D., former chief medical officer at CVS Health Corp. and Aetna, noted that the rule did not include prescription medications, which are often subject to PA — a process that draws the ire of providers who worry that delays could worsen patient outcomes. The CMS Interoperability and Prior Authorization Final Rule also required insurers to have a PA application programming interface (API), where providers can access information, although the regulation did not require them to disclose PA data on medications.  

Micky Tripathi, Ph.D., National Coordinator for Health Information Technology, touted the Biden administration’s progress on implementing regulations mandating the interoperability of health care systems and price transparency during a Feb. 22 Health Affairs event. He also described himself as an “AI optimist,” but emphasized the administration’s position that artificial intelligence tools must not exacerbate or worsen health inequities. 

With increasing interoperability and EHR adoption, Tripathi said, the Biden administration expects that providers, health plans and public health officials will be able to make smarter decisions using population health data. They will also have to meet standards set by the Office of the National Coordinator for Health Information Technology (ONC) to comply with quality measures used by CMS, among other organizations, Tripathi said. He also said that a focus on health equity is a key consideration in recent regulations governing AI. 

The federal government received 13 times more surprise billing disputes in the first half of 2023 than it initially estimated to receive over the course of a full calendar year, according to new CMS data.

The No Surprises Act (NSA), passed in 2021, established a Federal Independent Dispute Resolution (IDR) process that out-of-network providers and insurers can use to determine the OON rate for qualified IDR items or services after an unsuccessful open negotiation period. That process replaces the pre-NSA status quo of an OON provider sending a surprise bill to a patient. Of the 288,810 disputes filed through the Federal IDR portal over the first six months of 2023, about 46% were closed, with providers winning 77% of payment determinations.

This week, a growing chorus of criticism from state officials effectively stopped two proposed health insurer combinations in their tracks.  

One industry observer says SCAN Group and CareOregon’s now-scuttled deal, as well as Elevance Health, Inc.’s beleaguered bid to purchase Blue Cross Blue Shield of Louisiana, offer valuable lessons for companies hoping to combine in the future. 

“In both cases, the organizations proposing the merger spent over a year trying to convince stakeholders that the deal was a good thing, and after multiple efforts to generate support for the decision, gave up when that support did not materialize,” Michael Abrams, managing partner of the consulting firm Numerof & Associates, tells AIS Health, a division of MMIT.