/ en Thu, 07 Aug 2025 04:42:57 -0500 Fri, 01 Aug 25 15:42:55 -0500 /advisory/2025-08-01-regulatory-advisory-health-data-technology-and-interoperability-hti-4-fy-2026-final-rule <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) July 31 issued its hospital inpatient prospective payment system (PPS) and long-term care hospital (LTCH) PPS <a href="https://public-inspection.federalregister.gov/2025-14681.pdf?utm_campaign=pi+subscription+mailing+list&utm_medium=email&utm_source=federalregister.gov">final rule</a> for fiscal year (FY) 2026. Through the inpatient PPS, the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC) also finalized the Health Data, Technology, and Interoperability: Electronic Prescribing, Real-Time Prescription Benefit and Electronic Prior Authorization (HTI-4) rule.</p><p>The AHA will issue separate advisories on both the inpatient and LTCH PPS-related proposals.</p><div><h2 id="keyhighlights">Key Highlights</h2><p>ASTP/ONC’s changes will:</p><ul><li>Adopt three new certification criteria to support more efficient electronic prior authorization processing.</li><li>Update electronic prescribing certification criterion based on the National Council for Prescription Drug Programs (NCPDP) SCRIPT standard version 2023011.</li><li>Adopt a new real-time prescription benefit certification criterion based on NCPDP Real-Time Prescription Benefit standard version 13.</li><li>Adopt two additional health information technology (IT) certification criteria for modular Application Programming Interface (API) capabilities.</li><li>Adopt a series of implementation specifications for the exchange of clinical, administrative, formulary and provider directory information.</li></ul></div><h2>AHA TAKE</h2><p>We appreciate and support the administration’s efforts to reduce administrative burden and improve workflow automation, particularly when it comes to onerous prior authorization requirements. Providers have long advocated for the creation of electronic prior authorization standards that integrate with provider information systems to support an end-to-end automated prior authorization process. HTI-4's electronic prior authorization certification criteria will enable providers to access and share data more efficiently, thereby reducing burden and supporting more timely patient access to care. </p><p>Specifically, the criteria enable providers using certified health IT to request information from payers about a patient's coverage requirements, determine and assemble the information needed to support a prior authorization request, and submit that request directly from their certified health IT system.</p><p>We look forward to working with the administration on these and other opportunities to improve operational workflow and support more timely and transparent clinical decision-making.</p><h2>WHAT YOU CAN DO</h2><p><strong>Share </strong>this advisory with your chief information officer and other members of your senior management team.</p><h2>BACKGROUND</h2><p>In the 2024 Health Data, Technology, and Interoperability: Patient Engagement, Information Sharing, and Public Health Interoperability proposed rule (HTI-2 Proposed Rule), ASTP/ONC proposed a wide-ranging set of updates to the ONC Health IT Certification Program. Hospitals participating in CMS’ Promoting Interoperability Program are required to use health IT that meets ASTP/ONC’s certification criteria. HTI-4, which is being published as part of the FY 2026 inpatient hospital PPS final rule, adopts a limited subset of the proposals in the HTI-2 proposed rule. These new policies are related to electronic prior authorization, electronic prescribing, and real-time prescription benefit criterion, and ASTP/ONC has opted to call them HTI-4.</p><h2>ELECTRONIC PRIOR AUTHORIZATION</h2><p>The HTI-4 final rule adopts three new certification criteria to support more efficient electronic prior authorization processing and reduce administrative burden for providers. These criteria are based on Fast Healthcare Interoperability Resources (FHIR) implementation specifications developed by the HL7 Da Vinci project. The three criteria are:</p><ul><li>Provider Prior Authorization API — Coverage Requirements Discovery</li><li>Provider Prior Authorization API — Documentation Templates and Rules</li><li>Provider Prior Authorization API — Prior Authorization Support</li></ul><h2>MINIMUM STANDARDS CODE SETS UPDATES</h2><p>ASTP/ONC has routinely updated “minimum standards” code sets to account for updated versions of vocabulary standards used in certification criteria for various data elements. This ensures that developers adhere to baseline versions of code sets to support interoperability. </p><p>ASTP/ONC through HTI-4 finalizes proposals for minimum standard code sets relevant to medications. Specifically, the agency finalizes adoption of the Dec. 4, 2023, version of RxNorm, although it did not finalize expiration dates for previous releases of RxNorm. In the HTI-2 proposed rule, ASTP/ONC proposed an expiration date of Jan. 1, 2028, for the RxNorm July 5, 2022, release and an expiration date of Jan.1, 2026, for the RxNorm Sept. 8, 2015, release. As RxNorm is identified as a minimum standard code set, any release of RxNorm that is adopted in regulation serves as the baseline for certification. Given the flexibility available for the minimum standard code sets use, the agency believed finalizing expiration dates for certain older versions of RxNorm may lead to confusion, so it did not finalize expiration dates for these versions. Health IT developers may voluntarily move to updated RxNorm releases.</p><h2>REVISED ELECTRONIC PRESCRIBING CERTIFICATION CRITERION</h2><p>Electronic prescribing enables hospitals and other providers to share patient prescriptions with pharmacies through electronic health records (EHRs) and depends upon standards to enable data exchange. HTI-4 finalizes proposals related to the electronic prescribing criterion with modifications. For technology certified after June 30, 2020, health IT developers must update the Health IT Module to use the NCPDP SCRIPT standard version 2023011 and provide that update to their customers to maintain certification of the Health IT Module by Jan. 1, 2028. Additionally, any Health IT Modules for which a health IT developer seeks certification to the updated criterion using NCPDP SCRIPT standard version 2023011 would need to support electronic prior authorization transactions in accordance with the standard.</p><h2>NEW REAL-TIME PRESCRIPTION BENEFIT CRITERION</h2><p>HTI-4 also finalizes a proposal to adopt a new real-time prescription benefit certification criterion in accordance with certain requirements set forth in the Consolidated Appropriations Act of 2021. The finalized certification criterion is based on the NCPDP Real-Time Prescription Benefit standard version 13. ASTP/ONC also finalizes a proposal to include this certification criterion in the Base EHR definition after Jan. 1, 2028. Any Health IT Module presented for certification to the electronic prescribing criterion must also be certified to the real-time prescription benefit criterion.</p><h2>NEW CERTIFICATION CRITERIA FOR MODULAR API CAPABILITIES</h2><p>ASTP/ONC finalizes two health IT certification criteria for modular API capabilities. The HTI-2 proposed rule identified modular API capabilities as a new category of certification criteria, which defined modular and foundational capabilities necessary to support APIs across clinical, public health, administrative and other use cases. The establishment of this new category of certification was intended to provide flexibility for health IT developers who wish to certify more discrete functions, rather than large, multi-functionality and all-encompassing certification criteria.</p><p>The two certification criteria for modular API capabilities finalized in HTI-4 are referenced as conditional or as required functionality for other finalized certification criteria in HTI-4. The new certification criteria create flexibility to test and certify Health IT Modules and introduce new technical functionalities with other certification criteria that were finalized.</p><p>The two certification criteria include:</p><ul><li>Workflow triggers for decision support interventions — Client</li><li>Subscriptions — Client</li></ul><h2>ADDITIONAL IMPLEMENTATION SPECIFICATIONS FOR PROVIDER, PATIENT AND PAYER APIS</h2><p>HTI-4 also finalizes seven implementation specifications related to the exchange of clinical, administrative, formulary and provider directory information.</p><p>These include:</p><ul><li>HL7 FHIR Da Vinci — Coverage Requirements Discovery (CRD) Implementation Guide, Version 2.0.1 — STU 2</li><li>HL7 FHIR Da Vinci — Documentation Templates and Rules (DTR) Implementation Guide, Version 2.0.1 — STU 2</li><li>HL7 FHIR Da Vinci — Prior Authorization Support (PAS) FHIR Implementation Guide, Version 2.0.1 — STU 2</li><li>HL7 FHIR CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®) Implementation Guide, Version 2.0.0 — STU 2 US</li><li>HL7 FHIR Da Vinci — Payer Data Exchange (PDex) Implementation Guide, Version 2.1.0 — STU 2.1</li><li>HL7 FHIR Da Vinci — PDex US Drug Formulary Implementation Guide, Version 2.0.1 – STU 2</li><li>HL7 FHIR Da Vinci — PDex Plan Net Implementation Guide, Version 1.1.0 —STU 1.1 US</li></ul><p>CRD, DTR and PAS implementation guides were finalized to support criteria for electronic prior authorization. The remaining four implementation guides were finalized to support payers implementing APIs established in the Interoperability and Prior Authorization Final Rule.</p><h2>FURTHER QUESTIONS</h2><p>For further questions, please contact Jennifer Holloman, AHA’s director of health information technology policy, at <a href="mailto:jholloman@aha.org">jholloman@aha.org</a>, or Andrea Preisler, AHA’s senior associate director of administrative simplification policy, at <a href="mailto:apreisler@aha.org">apreisler@aha.org</a>, for any questions about prior authorization. </p></div><div class="col-md-4"><a href="/system/files/media/file/2025/08/health-data-technology-interoperability-electronic-prescribing-real-time-prescription-benefit-electronic-prior-authorization-advisory-8-1-2025.pdf" target="_blank" title="Click here to download the Regulatory Advisory: Health Data, Technology, and Interoperability: Electronic Prescribing, Real-Time Prescription Benefit and Electronic Prior Authorization PDF."><img src="/sites/default/files/2025-08/cover-health-data-technology-interoperability-electronic-prescribing-real-time-prescription-benefit-electronic-prior-authorization-advisory-8-1-2025.png" data-entity-uuid data-entity-type="file" alt="Health Data, Technology, and Interoperability: Electronic Prescribing, Real-Time Prescription Benefit and Electronic Prior Authorization Cover." width="640" height="834"></a></div></div></div> Fri, 01 Aug 2025 15:42:55 -0500 Prior Authorization /news/headline/2025-06-27-cms-announces-new-prior-authorization-program-pilot <p>The Centers for Medicare & Medicaid Services June 27 <a href="https://www.cms.gov/newsroom/press-releases/cms-launches-new-model-target-wasteful-inappropriate-services-original-medicare" title="rollout">announced</a> the rollout of a 6-year technology-enabled prior authorization program pilot. Through the Wasteful and Inappropriate Service Reduction Model pilot, CMS will partner with third-party entities to implement a technology-based prior authorization program for a specified list of services delivered to patients with traditional fee-for-service Medicare. Under the regionally based model, participating providers will have the choice of submitting prior authorization requests for selected items and services or subjecting their post-service claim to pre-payment medical review. </p> Fri, 27 Jun 2025 16:28:14 -0500 Prior Authorization /news/headline/2025-06-23-hhs-announces-initiative-insurers-streamline-prior-authorizations <p>The Department of Health and Human Services June 23 <a href="https://www.hhs.gov/press-room/kennedy-oz-cms-secure-healthcare-industry-pledge-to-fix-prior-authorization-system.html">announced</a> an initiative coordinated with multiple health insurance companies to streamline prior authorization processes for patients covered by Medicare Advantage, Medicaid managed care plans, Health Insurance Marketplace plans and commercial plans. Under the initiative, electronic prior authorization requests would become standardized by 2027. HHS stated that these reforms complement ongoing regulatory efforts by the Centers for Medicare & Medicaid Services to improve prior authorization, including building upon the Interoperability and Prior Authorization final rule. <br> <br>The plan is expected to make the prior authorization process faster, more efficient and more transparent, the agency said. Participating insurers pledged to expand real-time responses by 2027. HHS said that the insurers would also commit to reducing the volume of medical services subject to prior authorization by 2026, including those for common procedures such as colonoscopies and cataract surgeries. <br><br>During a news conference, HHS Secretary Robert F. Kennedy Jr. said unlike previous attempts by insurers, this initiative would succeed because the number of insurers participating represent 257 million Americans. “The other difference is we have standards this time,” he said. “We have ... deliverables. We have specificity on those deliverables, we have metrics, and we have deadlines, and we have oversight.” <br> <br>Mehmet Oz, M.D., CMS administrator, said that the pledge “is an opportunity for industry to show itself.” Sen. Marshall, R-Kan., said that Congress could pursue codifying at least some portions of the initiative in the future. <br><br>Additionally, participating insurers would honor existing prior authorizations during coverage transitions. <br> </p> Mon, 23 Jun 2025 16:31:45 -0500 Prior Authorization /lettercomment/2025-06-16-aha-comments-cms-and-astponc-request-information-re-health-technology-ecosystem <p>June 16, 2025</p><p>The Honorable Thomas Keane, M.D.<br>Assistant Secretary for Technology Policy<br>National Coordinator for Health Information Technology<br>Department of Health and Human Services<br>Attention: CMS-0042-NC<br>P.O. Box 8013<br>Baltimore, MD 21244-8013</p><p>The Honorable Stephanie Carlton<br>Deputy Administrator and Chief of Staff<br>Centers for Medicare & Medicaid Services<br>Department of Health and Human Services<br>Attention: CMS-0042-NC<br>P.O. Box 8013<br>Baltimore, MD 21244-8013</p><p><em>Submitted Electronically</em></p><p><em><strong>RE: CMS-0042-NC Request for Information; Health Technology Ecosystem</strong></em></p><p>Dear Assistant Secretary Keane and Deputy Administrator Carlton,</p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) appreciates the opportunity to provide comment on the Centers for Medicare & Medicaid Services (CMS) and Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC) Request for Information (RFI) regarding the Health Technology Ecosystem.</p><p>We support the agencies’ goals of reducing barriers for data interoperability and fostering innovation to support better health outcomes. The AHA recognizes the pivotal role that health technology plays in care delivery today and its potential to transform the patient and provider experience in the future. From artificial intelligence (AI) to mobile apps, medical devices to electronic health records (EHRs) — technology supports improvements in quality and efficiency for patients, caregivers and providers. Moreover, we believe that technology and data interoperability have the potential to address some of the prevalent challenges confronting the health care ecosystem today, including provider burnout and staffing shortages driven by administrative burdens. We also recognize that the innovative applications of health information technology (IT) must be balanced with reasonable guardrails to protect sensitive patient data and ensure security and privacy. In addition, while health technology can make care more efficient, implementing new tools and standards often requires significant financial investment and workflow changes for health care providers. This makes it critical for policymakers to ensure that policy changes intended to spur adoption are scoped and paced sustainably.</p><p>The AHA has several recommendations to improve health IT standards and infrastructure, increase beneficiary access to effective digital health tools, and advance data availability to improve health outcomes. Specifically, we recommend that CMS and ASTP/ONC:</p><ul><li>Foster a sustainable pace of standards implementation by continuing to develop ASTP/ONC’s United States Core Data for Interoperability vocabulary standards (USCDI), and extending the timeline to transition from USCDI version 3 to USCDI version 4 by an additional year (through calendar year (CY) 2028).</li><li>Collaborate across agencies to address broader infrastructure challenges associated with health IT adoption, such as lack of broadband, digital literacy training and reliable Wi-Fi access for rural and underserved communities.</li><li>Support reimbursement for the use of health technology by clarifying guidance on digital health and interprofessional consultation billing codes, and develop pathways to provide provisional payment for new technologies.</li><li>Promote accountability and engagement from payers on interoperability by requiring that impacted payers adopt and use certified payer application programming interfaces (APIs) and developing safety and security requirements for the Provider Directory APIs.</li><li>Repeal provider disincentives in the June 2024 final rule “21st Century Cures Act: Establishment of Disincentives for Healthcare Providers That Have Committed Information Blocking.” Under the final rule, hospitals and providers found to engage in information blocking may face excessive reductions in payment, which threatens access to services (particularly in rural and underserved areas).</li><li>Build additional infrastructure to provide oversight for Trusted Exchange Framework and Common Agreement (TEFCA), including establishing an attestation schedule for all qualified health information networks (QHINs)</li><li>Provide protections to ensure hospitals or health systems that have a QHIN that is suspended or terminated are not held liable for information blocking claims.</li><li>Advance administrative simplification efforts by establishing a standard transaction for clinical attachments to support claims.</li><li>Streamline current price transparency policies to remove complexity from the patient experience by focusing on options for patient estimates and other pricing information. Rely on No Surprises Act good faith estimates (GFEs) and advanced explanation of benefits (AEOBs) to provide patients with the most accurate estimates for their courses of care.</li><li>Provide incentives for technology investment to enable providers to transition to value-based arrangements.</li><li>Revert to previous thresholds (i.e., percentage threshold for the number of clinicians meeting certified electronic health record requirements) for the Medicare Shared Savings Program promoting interoperability measures.</li></ul><p>There are other areas relevant to the health technology ecosystem that were not directly addressed in the RFI, including cybersecurity. We included several health IT and cybersecurity-focused recommendations in our recent response to the Office of Management and Budget's RFI on deregulation, including modifying the HIPAA cybersecurity rule of December 2024 to make the requirements voluntary.<sup>1</sup></p><p>Our detailed comments are attached. We look forward to the opportunity to work with CMS, ASTP/ONC and the Department of Health and Human Services (HHS) to help realize technology’s full potential for improving health outcomes, fully engaging patients in managing their health and reducing administrative burden. Please contact me if you have questions, or feel free to have a member of your team contact Jennifer Holloman, AHA director of health IT policy, at <a href="mailto:jholloman@aha.org">jholloman@aha.org</a>.</p><p>Sincerely,</p><p>/s/</p><p>Ashley Thompson<br>Senior Vice President<br>Public Policy Analysis and Development</p><p>__________</p><p><sup>1</sup> <a href="/system/files/media/file/2025/05/aha-response-to-omb-deregulation-rfi-letter-5-12-2025.pdf"><small class="sm">/system/files/media/file/2025/05/aha-response-to-omb-deregulation-rfi-letter-5-12-2025.pdf</small></a><br> </p> Mon, 16 Jun 2025 13:30:11 -0500 Prior Authorization /news/headline/2025-05-30-gao-says-cms-should-target-behavioral-health-services-prior-authorization-audits <p>The Government Accountability Office May 29 released a <a href="https://www.gao.gov/products/gao-25-107342" target="_blank">report</a> recommending the Centers for Medicare & Medicaid Services target behavioral health services when auditing Medicare Advantage plans’ use of prior authorization. CMS said it currently does not target behavioral health services because they make up a small percentage of MA services, the report said.     </p><p>The report describes selected MA organizations’ prior authorization requirements and use of internal coverage criteria for prior authorization decisions on behavioral health services. It also examines CMS’ oversight of the use of internal coverage criteria, among other issues. GAO said that CMS “would take the recommendation under advisement in the future.” </p> Fri, 30 May 2025 15:23:53 -0500 Prior Authorization /lettercomment/2025-05-21-aha-senate-letter-supporting-improving-seniors-timely-access-care-act <div class="container"><div class="row"><div class="col-md-8"><p>May 21, 2025</p><div class="row"><div class="col-md-6"><p>The Honorable Roger Marshall, M.D.<br>United States Senate<br>479A Russell Senate Office Building<br>Washington, DC 20510</p></div><div class="col-md-6"><p>The Honorable Mark Warner<br>United States Senate<br>703 Hart Senate Office Building<br>Washington, DC 20510</p></div></div><p>Dear Senators Marshall and Warner:</p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) is pleased to support your legislation, the Improving Seniors’ Timely Access to Care Act.</p><p>Inefficient prior authorization requirements are a pervasive problem among certain plans in the Medicare Advantage (MA) program that result in delays in care and add financial burden and strain to the health care system. Your bipartisan legislation would address these issues through streamlining prior authorization requirements under MA plans by eliminating complexity and promoting uniformity that would reduce the wide variation in prior authorization methods that frustrate both patients and providers.</p><p>Specifically, your bill would establish an electronic prior authorization standard to streamline approvals, reduce the time a health plan is allowed to consider a prior authorization request, require MA plans to report on their use of prior authorization, including the use of artificial intelligence in prior authorization and the rate of approvals and denials, and encourage MA plans to adopt policies that adhere to evidence-based guidelines.</p><p>Thank you for your support in improving the prior authorization process to increase patient access to care and reduce the burden for providers. We look forward to continuing to work with you on this issue and urge Congress to pass this bill to ensure all Medicare beneficiaries have access to timely and appropriate care.</p><p>Sincerely,<br>/s/<br>Stacey Hughes<br>Executive Vice President</p></div><div class="col-md-4"><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2025/05/aha-senate-letter-supporting-improving-seniors-timely-access-to-care-act-5-21-2025.pdf" target="_blank" title="Click here to download the AHA Senate Letter Supporting Improving Seniors’ Timely Access to Care Act PDF.">Download the Letter PDF</a></div></div></div></div> Wed, 21 May 2025 14:01:38 -0500 Prior Authorization /lettercomment/2025-05-21-aha-house-letter-supporting-improving-seniors-timely-access-care-act <div class="container"><div class="row"><div class="col-md-8"><p>May 21, 2025</p><div class="row"><div class="col-md-6"><p>The Honorable Mike Kelly<br>U.S. House of Representatives<br>1707 Longworth House Office Building<br>Washington, DC 20515</p></div><div class="col-md-6"><p>The Honorable Ami Bera, M.D.<br>U.S. House of Representatives<br>172 Cannon House Office Building<br>Washington, DC 20515</p></div></div><div class="row"><div class="col-md-6"><p>The Honorable Suzan DelBene<br>U.S. House of Representatives<br>2311 Rayburn House Office Building<br>Washington, DC 20515</p></div><div class="col-md-6"><p>The Honorable John Joyce, M.D.<br>U.S. House of Representatives<br>2102 Rayburn House Office Building<br>Washington, DC 20515</p></div></div><p>Dear Representatives Kelly, DelBene, Bera and Joyce:</p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) is pleased to support your legislation, the Improving Seniors’ Timely Access to Care Act.</p><p>Inefficient prior authorization requirements are a pervasive problem among certain plans in the Medicare Advantage (MA) program that result in delays in care and add financial burden and strain to the health care system. Your bipartisan legislation would address these issues through streamlining prior authorization requirements under MA plans by eliminating complexity and promoting uniformity that would reduce the wide variation in prior authorization methods that frustrate both patients and providers.</p><p>Specifically, your bill would establish an electronic prior authorization standard to streamline approvals, reduce the time a health plan is allowed to consider a prior authorization request, require MA plans to report on their use of prior authorization, including the use of artificial intelligence in prior authorization and the rate of approvals and denials, and encourage MA plans to adopt policies that adhere to evidence-based guidelines.</p><p>Thank you for your support in improving the prior authorization process to increase patient access to care and reduce the burden for providers. We look forward to continuing to work with you on this issue and urge Congress to pass this bill to ensure all Medicare beneficiaries have access to timely and appropriate care.<br> </p><p>Sincerely,<br>/s/<br>Stacey Hughes<br>Executive Vice President</p></div><div class="col-md-4"><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2025/05/aha-house-letter-supporting-improving-seniors-timely-access-to-care-act-5-21-2025.pdf" target="_blank" title="Click her to download the AHA House Letter Supporting Improving Seniors’ Timely Access to Care Act PDF.">Download the Letter PDF</a></div></div></div></div> Wed, 21 May 2025 13:05:17 -0500 Prior Authorization /news/headline/2025-03-20-study-finds-90-medicaid-managed-care-plans-cover-least-one-aud-medication-without-priority-and <p>A JAMA Network Open <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2831362" target="_blank">study</a> published March 13 found that 90% of Medicaid managed care plans cover at least one alcohol use disorder medication without prior authorization and quantity limits. It also noted that while Medicaid managed care plans are the largest payer for addiction treatment services, approximately 43% cover all four AUD treatments approved by the Food and Drug Administration.  </p><p>“This study suggests that efforts to expand AUD medication prescribing may be limited by gaps in health insurance coverage,” the study notes. “Medicaid MCPs and states can support AUD medication utilization by covering these medications without applying utilization management strategies.” </p> Thu, 20 Mar 2025 14:49:33 -0500 Prior Authorization /news/headline/2025-02-12-report-highlights-how-health-care-can-avoid-20-billion-spending <p>The Council for Affordable Quality Healthcare Feb. 11 released a <a href="https://www.caqh.org/hubfs/Index/2024%20Index%20Report/CAQH_IndexReport_2024_FINAL.pdf">report</a>  highlighting how the health care industry can save $20 billion by transitioning from manual to electronic workflows.  <br>  <br>In addition, it found that the industry could save $515 million annually on electronic prior authorizations and save providers and staff 14 minutes per transaction.</p> Wed, 12 Feb 2025 16:06:21 -0600 Prior Authorization /news/headline/2025-01-29-kff-ma-insurers-made-nearly-50-million-prior-authorization-determinations-2023 <p>An <a href="https://www.kff.org/medicare/issue-brief/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/">analysis</a> by KFF released Jan. 28 found that Medicare Advantage insurers made nearly 50 million prior authorization determinations in 2023. The finding reflects continued year-over-year increases from 2022 (42 million) and 2021 (37 million) as more people have enrolled in MA. KFF also found that in 2023 there was an average of nearly two prior authorization determinations per MA enrollee. <br><br>The analysis found that insurers fully or partially denied 3.2 million prior authorization requests (6.4%) in 2023, a smaller share than 2022 (7.4%). In 2023, 11.7% of denied prior authorization requests were appealed in MA and of those cases, 81.7% were partially or fully overturned.</p> Wed, 29 Jan 2025 15:38:18 -0600 Prior Authorization