CMS Proposes Electronic Prior Authorization for Providers and Payers
The Centers for Medicare & Medicaid Services (CMS) this week released a proposed rule that would require certain providers and payers to implement an electronic prior-authorization process, shorten the timeframe for payers to respond to prior-authorization requests, and work to make the prior-authorization process more efficient and transparent.
An announcement from CMS said the proposed requirements would apply to Medicare Advantage (MA) organizations, state Medicaid and Children’s Health Insurance Program (CHIP) agencies, Medicaid managed care plans, CHIP managed care entities, and qualified health plan issuers on the federally facilitated exchanges. The agency estimates that these proposed policies could create efficiencies that would save physician practices and hospitals more than $15 billion over a 10-year period.
The rule would automate essential prior-authorization functions related to documentation, requests, and decisions. Also, payers would be required to provide a clear reason for denials and to respond to urgent prior-authorization requests within 72 hours and standard requests within seven days.
The proposed electronic platform is the already-established “Patient Access API,” which uses the Health Level 7
® format. The rule also would enhance patients’ access to their own information on prior- authorization requests, approvals, and related information by requiring online reporting of certain performance metrics.
CMS is seeking information from stakeholders on the following topics:
- How to standardize data on patients’ social risk factors (e.g., housing instability, food insecurity) that influence patient health and health care utilization;
- How to advance electronic data exchange among behavioral health providers;
- How to improve the exchange of medical documentation between and among providers/suppliers and patients (for the purpose of care coordination);
- How to enable the connection of health information networks to advance cross-organization interoperability, such as the prior-authorization improvements in this rule, including incentives for payers; and
- Evidence-based policies that CMS could pursue to leverage health IT, data sharing, and interoperability to improve maternal health outcomes.
NABH will address these and the rule’s other key provisions in the association’s formal comments. CMS will publish the rule in the
Federal Register on Dec. 13, 2022 and accept comments through March 13, 2023.
Biden Administration Launches Opioid Overdose Dashboard
The Biden Administration on Thursday unveiled a website featuring the Office of National Drug Control Policy’s (ONDCP) new
Opioid Overdose Tracker to monitor non-fatal, opioid overdoses in the pre-hospital setting in an effort to prevent overdose deaths.
Non-fatal overdoses are a good predictor of fatal overdoses, Biden administration officials said during a news briefing Wednesday according to
Politico. People who experience at least one non-fatal overdose are about two to three times more likely to eventually die from one, they said. Earlier this year, the Centers for Disease Control and Prevention estimated that 80,816 Americans died from opioid overdoses in 2021, increasing from an estimated 70,029 in 2020.
Using data submitted to the National Emergency Medical Services Information System (NEMSIS), the new dashboard contains one interactive page with a geo-surveillance view, and its data set includes all de-duplicated Emergency Medical Services (EMS) patient care reports for a rolling time period that meet specific
inclusion criteria.
In 2022, all 50 states, three territories (the Virgin Islands, Guam, and the Northern Mariana Islands), and Washington, D.C. had submitted data to the national database, according to NEMSIS. The NEMSIS Technical Assistance Center collects data from about 95% of all EMS agencies in the United States that respond to 911 requests for emergency care and transport patients to acute care facilities.
According to a National Public Radio story, ONDCP Director Rahul Gupta, M.D. told reporters during a call that “We could see tens of thousands of additional lives saved” with the new tool, which Gupta said he hopes first responders, clinicians, and policymakers will use to connect people to care and also minimize response times and ensure that resources are available.
NABH has advocated that the dashboard be updated in 2023 to use numbers at the state and county levels, as well as the national level.
New Report Shows Number of Patients Receiving Medications for Opioid Use Disorders in OTPs
Of the 512,224 patients in Opioid Treatment Programs (OTPs) who reported using medications for opioid use disorders (MOUDs), 476,763 reported using methadone, 33,473 reported buprenorphine, and the remaining 1,988 reported using naltrexone, according to a new
report from the National Association of State Alcohol and Drug Abuse Directors (NASADAD).
NASADAD partnered with the American Association for the Treatment of Opioid Dependence (AATOD) for the study, which was funded to determine the number of patients who receive MOUDs in OTPs, the types of federally approved medications that patients use in treatment, and the specific formulations of medication used among the patient population.
Researchers analyzed data from 1,547 Opioid Treatment Programs (OTPs) nationwide that completed the survey, reflecting an 85-percent response rate. The Substance Abuse and Mental Health Services Administration funded the study through the agency’s Opioid Response Network.
MedPAC Discusses Draft Recommendations for 2024 Physician Payment Increases
The Medicare Payment Advisory Commission (MedPAC) this week discussed draft recommendations to increase the Medicare base payment rate for physician and other health professional services by 1.25% in 2024, a rate that is half of the forecasted increase in the Medicare Economic Index for 2024.
Current law calls for no updates to 2024 payment rates relative to 2023 levels. The commission also discussed supporting a payment add-on for services for low-income Medicare beneficiaries (15% for primary care; 5% for non-primary care), which new Medicare spending would fund.
The purpose of these items is to help maintain access to physician services for Medicare beneficiaries. Both measures received substantial support from the commissioners, and they are expected to be approved as formal recommendations to Congress when MedPAC convenes in January to vote on these and other Medicare payment adequacy recommendations for 2024.
HHS Highlights Progress to Mark One-Year Anniversary of HHS’ Overdose Prevention Strategy
Since the Biden administration released its Overdose Prevention Strategy a year ago, the number of healthcare providers with waivers to prescribe buprenorphine for opioid use disorder increased by 19% and the number of naloxone prescriptions filled in pharmacies has increased by 37%, HHS
announced late last week.
The announcements were made in conjunction with a news conference HHS Secretary Xavier Becerra held to mark the first anniversary of the Biden administration’s Overdose Prevention Strategy. During the news conference, Becerra highlighted some of the strategy’s recent actions, including an announcement from the Centers for Disease Control and Prevention (CDC) that state, local, and territorial awardees of the CDC Overdose Data to Action cooperative agreement can use a portion of their funds to purchase naloxone; and the U.S. Food and Drug Administration’s
notice last month that certain naloxone products have the potential to be safe and effective for over-the-counter use.
HRSA to Invest $20 Million in Grants to Reduce Neonatal Abstinence Syndrome in Rural Settings
The Health Resources and Services Administration’s (HRSA) Federal Office of Rural Health Policy will invest $20 million in about 40 grants to reduce the incidence of neonatal abstinence syndrome (NAS) in the nation’s rural communities.
According to HRSA’s announcement, grant recipients will collaborate with local, state, and regional stakeholders to provide coordinated, trauma-informed, and family centered behavioral and maternal healthcare services—including medication-assisted treatment—to rural pregnant and post-partum women and their families.
Applicant organizations may be in either an urban or rural area; however, all activities supported by the program must exclusively occur in HRSA-designated, rural
areas.
HRSA will offer a
webinar for applicants on Wednesday, Jan. 4, 2023 from 2 p.m. to 3 p.m. ET; registration is
not required. The agency will accept applications through March 8, 2023.
Reminder: Please Submit Data to Enhance NABH’s Managed-Care Advocacy Efforts
Thank you to all members who have submitted data to NABH’s denial-of-care portal. Your data will help NABH highlight problems in the field related to health plan denials and timeliness.
Several policymaking entities are interested in these data, which could support advocacy for expanded access to care. For new participants, please e-mail
Emily Wilkins, NABH’s administrative coordinator, for support.
Save the Date for the NABH 2023 Annual Meeting!
Please mark your calendars and plan to join us in Washington, DC from
June 12-14, 2023 for next year’s NABH Annual Meeting!
Fact of the Week
A new
study published in
The Lancet Psychiatry found that people with severe mental illness have an elevated risk for several chronic health problems even before they receive their first diagnosis of a severe mental illness.
For questions or comments about this CEO Update, please contact Jessica Zigmond.