|House Passes Medicare Advantage Prior Authorization Oversight Bill
By Maya Goldman | September 14, 2022
Medicare Advantage carriers would be subject to new requirements governing the prior authorization process under legislation that passed the House Wednesday.
The measure would compel Medicare Advantage insurers to use electronic prior authorization programs, annually submit lists of items and services subject to prior authorization, and adopt beneficiary protection standards. The Improving Seniors’ Timely Access to Care Act now moves the Senate, where supporters hope it will advance after the November congressional elections.
Prior authorization in Medicare Advantage has come under fire this year. Approximately 13% of denied prior authorization requests during a week-long period in June 2019 met fee-for-service Medicare coverage rules, according to a Health and Human Services Department report released in April. Hospitals have called on the Justice Department to use the False Claims Act against Medicare Advantage insurers that improperly deny coverage.
The legislation, first introduced in 2019, is a rare bipartisan healthcare initiative that boasts more than 300 cosponsors in the House and support from both provider and insurance groups.
After the vote, lawmakers who led the measure through the House called on the Senate and President Joe Biden to advance it into law.
“Seniors and their families should be focused on getting the care they need, not faxing forms multiple times for procedures that are routinely approved. This takes away valuable time from providers who on average spend 13 hours a week on administrative paperwork related to prior authorization,” Reps. Suzan DelBene (D-Wash.), Ami Bera (D-Calif.), Larry Bucshon (R-Ind.) and Mike Kelly (R-Pa.) said in a joint news release.
Advocates are optimistic about the bill’s chances in the Senate. “We are encouraged by conversations with Senate bill champions and leaders that the legislation could be included in an end-of-year omnibus package,” said Peggy Tighe, a healthcare lobbyist and legislative counsel to the Regulatory Relief Coalition, an umbrella group comprising physician organizations.
To read more, go to Modern Healthcare.
|Majority of Providers Say Fee-for-Service is a Thing of the Past, Survey Finds
By Rylee Wilson | September 14, 2022
A majority of healthcare executives think value-based-care has replaced fee-for-service billing, a new survey found.
Of 160 C-suite executives and other high-level staff surveyed, just 4 percent said they think payers use traditional fee-for-service billing with no connection to quality and value. The majority of executives think payers use FFS models with connections to the quality and value of care taken into account.
The survey, conducted by business intelligence firm Morning Consult and health tech company Innovaccer, found just 1 percent of executives think FFS billing with no connection to value will be in use in 2025.
According to a Sept.14 news release, payers report that FFS billing with no account for value makes up more than 10 percent of billing, higher than providers estimated. “So, providers think the transition to value has substantially occurred, when in fact we’re only at the very beginning,” Brian Silverstein, MD, Innovaccer’s chief population health officer, said in the release. “The amount of financial risk providers have is going to increase significantly in the next few years.”
To read more, got to Becker’s Payer Issues.
|Specially Trained Radiographers Spot Breast Cancer At Rates Comparable to Radiologists
By Hannah Murphy | September 13, 2022
Radiographers trained to recognize certain findings on screening mammograms could help address the worldwide shortage of radiologists.
That’s according to new research published in Radiology that details a double reading method that is commonly used in Europe. Double reading involves a radiologist’s interpretation of imaging in addition to a non-radiologist’s input—in this case a specially trained radiographer.
The National Health Service Breast Screening Program (NHSBSP), which has more than 80 screening centers in England and completes more than 2 million screening mammograms annually, in the United Kingdom recruits radiographers who have completed extensive postgraduate education to assist in the interpretation of mammograms. This, in turn, helps reduce the workload burden of radiologists who are often short-staffed.
It sounds like a reasonable solution, but is it effective? According to the performance data derived from more than 1 million screening digital mammograms—yes. Researchers arrived at this conclusion after reviewing a year’s worth of interpretations from 224 radiologists and 177 radiographers from the NHSBSP, each of whom had completed quality assurance training specific to mammographic screening prior to the analysis. Reader performance was judged based on three metrics—cancer detection rates, recall rates and the positive predictive value of recalls based on biopsy-proven findings.
For cancer detection rates, researchers did not observe a significant difference between the radiologists and radiographers (7.84 per 1,000 vs 7.53). Recall rates were also neck and neck, at 5% for radiologists and 5.2% for radiographers. And the final performance metric—positive predictive value of recall—was also in line with the first two metrics for each group, at 17.1% for radiologists and 16.1% for radiographers.
To read more, go to Health Imaging.
|AMA Releases 2023 CPT Code Set, Aims to Reduce E/M Coding Burden
By Jacqueline LaPointe | September 12, 2022
The American Medical Association (AMA) has released the Current Procedural Terminology (CPT) code set for 2023, which contains updates that aim to reduce medical coding burden for evaluation and management (E/M) visits.
Providers use the CPT code set to document patient visits, including all services provided, and the codes are used to track utilization, measure quality of care, and create medical claims for payer reimbursement. Recently, the documentation and coding requirements for E/M visits were updated by CMS to streamline the process and address administrative burdens.
Specifically, in the 2020 Medicare Physician Fee Schedule Final Rule, CMS revised the code descriptors and documentation standards for E/M office visit CPT codes 99201 through 99215 as adopted by the AMA CPT Editorial Panel. Starting in 2021, the agency allowed providers to document E/M visits based on medical decision-making (MDM) or total time (versus the 1995/1997 E/M documentation guidelines).
Additionally, the new standards eliminated patient history and physical exam elements from the E/M coding process, when appropriate.
The 2023 CPT code set provides additional revisions to the rest of the E/M code section, AMA recently announced.
“The process for coding and documenting almost all E/M services is now simpler and more flexible,” Jack Resneck Jr, MD, president of the AMA, said in the announcement. “We want to ensure that physicians and other users get the full benefit of the administrative relief from the E/M code revisions. The AMA is helping physicians and [healthcare] organizations prepare now for the E/M coding changes and offers authoritative resources to anticipate the operational, infrastructural and administrative workflow adjustments that will result from the pending transition.”
AMA revised CPT coding guidelines across care settings and services to align with new E/M coding standards.
To read more, go to Revcycle Intelligence.