The CMS Interoperability and Prior Authorization Rules
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
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
On February 8, 2024, the U.S. Department of Health & Human Services (HHS) released a final rule modifying 42 CFR Part 2 (Part 2) provisions regarding the confidentiality of Substance Use Disorder (SUD) Patient Records. The...more
On December 13, 2022, the Centers for Medicare and Medicaid Services (“CMS”) issued a proposed rule, titled Advancing Interoperability and Improving Prior Authorization Processes (“Proposed Rule”), to improve patient and...more
On January 18, 2024, CMS released a pre-publication version of a final rule (the Final Rule) that will require Medicare Advantage organizations (MA or Part C), Medicaid and the Children’s Health Insurance Program (CHIP)...more
On January 17, 2024, the Centers for Medicare & Medicaid Services (CMS) released a final rule that will require certain payers to automate their prior authorization processes and implement application program interfaces...more
Last week CMS issued its final rule “CMS Interoperability and Prior Authorization” (CMS-0057-F), unchanged from its proposed rule in 2022, which addresses prior authorizations. Prior authorization, a “utilization management”...more
Congress Passes CR and Averts Government Shutdown. As appropriators continue to draft the 12 funding bills for FY 2024, a new stopgap CR was needed to avoid a partial government shutdown on January 19. The Senate passed the...more
n November 1, 2019, CMS posted the final rule establishing the payment rates for the Hospital Outpatient Prospective Payment System (OPPS) and the Ambulatory Surgery Center (ASC) Payment System for calendar year (CY) 2020...more
In the second episode of our series on the national opioid crisis, Gina Bertolini discusses the overlay of recent guidance concerning privacy laws such as the Health Insurance Portability and Accountability Act (HIPAA) and...more
On December 30, 2015, CMS published a final rule entitled: "Medicare Program; Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies," implementing Section 1834(a)(15) of the...more
On December 30, 2015, the Centers for Medicare & Medicaid Services (CMS) published its final rule establishing a prior authorization program for certain durable medical equipment, prosthetics, orthotics and supplies (DMEPOS)...more