AGG Talks: Home Health & Hospice Podcast - Episode 9: The Impact of AI and Prior Authorizations on Home Health and Hospice
The CMS Interoperability and Prior Authorization Rules
The last week of June was a busy one when it comes to news about prior authorization – a major tool used by health plans and the federal government to manage healthcare utilization. The week started with a commitment from...more
The Centers for Medicare & Medicaid Services (CMS) recently announced the launch of the Wasteful and Inappropriate Services Reduction (WISeR) Model, a six-year model under the CMS Innovation Center aimed at reducing...more
CMS recently announced a new model it will be using to pilot the use of artificial intelligence and machine learning in reviewing prior authorizations submitted for certain services CMS has identified as being at greater risk...more
Health plan members of AHIP and the Blue Cross and Blue Shield Association made news earlier this week when they announced a series of steps that a broad swath of health insurers will take to improve the prior authorization...more
The US Government Accountability Office (GAO) recently released a report on the Centers for Medicare and Medicaid Services (CMS)’s oversight of prior authorization criteria for behavioral health services (BHS) by Medicare...more
Last week, the Government Accountability Office (GAO) published a report determining that there is a nontrivial risk that prior authorization requirements, together with internal coverage criteria, may undermine the Medicare...more
Welcome to our fourth issue of 2025 of The Health Record -- our healthcare law insights e-newsletter. In this edition, we look at prior authorization transparency and physician decision-making; the impact of Medicaid cuts...more
Join the industry’s top litigators and leading plan counsel at ACI’s 16th Annual Advanced Forum on Managed Care Disputes and Litigation, for two days of discussions designed to address emerging areas of concern for MCOs in...more
Last week, the contract year (CY) 2026 Medicare Advantage (MA) and Part D final reg entered the clearance process at the Office of Management and Budget (OMB). As mentioned in a previous Regs & Eggs blog post, OMB’s review is...more
In this episode, AGG Healthcare attorneys Bill Dombi and Jason Bring discuss the role of managed care, artificial intelligence, and prior authorizations in home health and hospice. Bill and Jason examine a recent lawsuit...more
Traditional Medicare (Parts A and B) and Medicare Advantage (Part C, including additional vision, dental, and hearing benefits) plans aim to provide comprehensive medical benefits to American Seniors and adults with...more
Governor Newsom signed over 1300 bills and vetoed almost 190 bills in 2024. Consistent with prior years, in 2024, California enacted multiple laws significantly impacting the health care industry. From artificial intelligence...more
Over the past two years, federal and state government agencies have moved to regulate the deployment of artificial intelligence (AI) in the healthcare setting, including in the utilization management (UM) and prior...more
Learning Objectives: - Discuss the new regulations and subsequent CMS guidance applicable to MAOs regarding coverage criteria and prior authorization - Discuss the broader current landscape between MAOs and providers,...more
Healthcare lives on data. Getting it to the patient and providers is essential for delivering quality care, but that can be a challenge. As Eden Avraham-Katz, Vice President, Legal and Compliance at 1upHealth explains in...more
With recent CMS mandates and state-level reforms, the healthcare industry faces a pivotal moment to improve prior authorization processes, ensuring timely access to care and integrating health equity considerations....more
On April 5, 2023, the Centers for Medicare & Medicaid Services (CMS) published an expansive final rule amending Medicare Advantage (MA) regulations related to, among other things, coverage criteria and prior authorization....more
Below is Part II of our New Jersey Statutory update. As you can see from the below, several statutes were passed imposing requirements on health insurance payers, including new requirements for prior authorization request and...more
Holland & Knight Health Dose is an in-depth weekly dose of legislative and regulatory insights to keep stakeholders abreast of happenings in Washington, D.C., impacting the health sector....more
The Physician Practice Management (PPM) and ASC Symposium 2024 is the destination event for PPM and ASC industry leaders and health industry investors. Join us as we deliver actionable insights on the state of the market and...more
Plaintiff Jeremy Jong filed a putative class-action complaint against Blue Shield of California (Blue Shield), one of the largest medical insurance companies in the United States....more
The Centers for Medicare & Medicaid Services (CMS) recently published the CMS Advancing Interoperability and Improving Prior Authorization Processes Final Rule (“PA Final Rule”) in the Federal Register....more
As part of its ongoing mission to modernize and improve the interoperability of the health care system, on January 17, 2024, the Centers for Medicare & Medicaid Services (CMS) finalized the CMS Interoperability and Prior...more
Artificial Intelligence (AI), specifically generative AI technologies, hold significant promise for improving the healthcare industry by streamlining clinical operations, freeing service providers from mundane tasks, and...more