CMS Finalizes Prior Authorization Reform – Industry News, April 2023

CMS Finalized Prior Authorization Reform

On April 5, 2023, the Centers for Medicare and Medicaid Services (CMS) finalized rule that, in part, aims to remove barriers to care created by complex coverage criteria and utilization management for individuals with Medicare Advantage (MA).

Within the final rule, CMS implemented important protections regarding utilization management policies and coverage criteria to ensure MA enrollees receive the same access to care they would receive in traditional Medicare. The rule requires a granted prior authorization approval remain valid for as long as medically necessary to avoid disruptions in care. The rule also requires denials of coverage to be reviewed by health care professionals with relevant expertise before a denial can be issued. CMS is now also requiring Medicare Advantage plans to annually review utilization management policies.

At the end of March, UnitedHealthcare – the nation’s largest health insurance company- announced its plans to cut back the use of prior authorization. The health insurance company estimates it will remove 20% of its services and medications from its current prior authorizations list beginning in the third quarter of 2023. The reductions will be applicable for most commercial, Medicare Advantage and Medicaid enrollees. UHC also plans to launch their “national Gold Card Program” in 2024 for providers who meet certain requirements, eliminating the preapproval process for most procedures.

A recent large-scale analysis published in JAMA Health Forum found that radiation oncology, cardiology and diagnostic radiology were the three specialties with the highest rate of services subjected to prior authorizations from a large Medicare Advantage insurer.

Radiology Compliance Reminder Courtesy of DOJ

Following a settlement centered on allegations of improperly billed diagnostic radiology interpretations performed by resident physicians, the Department of Justice (DOJ) highlights an important compliance reminder to all radiology teaching programs.

The U.S. Attorney’s Office for the Northern District of Iowa and the University of Iowa (UI) entered into a settlement agreement where UI agreed to increase compliance training for their radiology teaching program and pay $16,444 to the United States. It is alleged that UI’s academic medical center submitted improper claims for payment to Medicare for services performed by resident physicians submitted under an attending teaching physician’s billing number. It was alleged, by the government, the review of the residents’ x-ray interpretations by the teaching physicians did not satisfy Medicare payment requirements the interpretation be reviewed or performed by a physician other than a resident.

As per Medicare Claims Processing Manual, Chapter 12, diagnostic imaging performed by a resident can be billed as physician services only when the attending teaching radiologist also personally reviews images and the resident’s interpretation and agrees with or edits the findings. The teaching physician does not fulfill Medicare payment requirements by only signing off on the resident’s interpretations without documenting their own physician work.

The settlement agreement serves as an important compliance reminder to radiology teaching programs. Attending radiologists must personally review and document their agreement or edits with a resident’s radiology reports in order for the services to be billed to Medicare.

Legislation Proposed to Update Physician Payments

On April 6, 2023, a bipartisan group of physician lawmakers introduced the Strengthening Medicare for Patients and Providers Act to the House of representatives.

The bill, which is drawing praise from the American College of Radiology (ACR) as well as other professional associations, proposes to provide a permanent annual physician payment update that would be tied to the Medicare Economic Index (MEI). The ACR, Society of Interventional Radiology (SIR) and more than 130 other professional groups wrote to congressional leaders in March asking to address the trend in overall decreased physician payments. The American Medical Association (AMA) estimates that, when adjusted for inflation in practice costs, Medicare physician payments have declined by 26% since 2021.

This proposal comes after the Medicare Payment Advisory Commission (MedPAC) recommended a physician payment update tied to half of the economic index. “Congress often waits until problematic situations become full-fledged crises. Members need to hear from their hometown physicians that we are nearing a crisis. Congress needs to pass this bill stat.” said AMA President Jack Resneck Jr., M.D.

Palmetto Releases IMRT Pre-Payment Review Results

The Medicare Administrative Contractor (MAC), Palmetto GBA has released their targeted probe to educate on the results for the pre-payment review for intensity modulated radiotherapy for October through December 2022.

Of the 120 claims reviewed from North Carolina, South Carolina, Virginia, and West Virginia, 34 were denied, a 28% rate of denial. The 120 claims equaled $463,724.94 of which, $35,911.12 was denied. Of the claims denied, 60% were due to no documentation of medical necessity while the other 40% were denied due to the recommended protocol not being ordered or followed.

For denials due to no documentation of medical necessity, Palmetto advises the following:

  • Submit all documentation related to the services billed which support the medical necessity of the services. Documentation should support:
    • A covered indication or condition for the service billed
    • A physician/NPP is managing the care of the covered indication or condition
    •  Any medical history that supports a need for the service
    • Any diagnostic results or symptomology that supports a need for the service
  • A legible physician or nonphysician provider (NPP) signature is required on all documentation necessary to support medical necessity
  • Use the most appropriate ICD-10-CM codes to identify the beneficiary’s medical diagnosis

For denials due to the recommended protocol not ordered and/or followed, Palmetto recommends the following:

  • Clear physician/radiation oncologist orders for radiation treatment course, including specific anatomical target volumes, treatment technique, current dosage, type of radiation measuring and monitoring devices to be used and treatment fields
  • Relevant medical history documented prior to the DOS and signed by the physician/radiation oncologist or appropriate nonphysician provider to include:
    • Clear indication of the diagnosis being treated and medical necessity of the services
    • Supporting reports such as dosimetry, physicist, simulation, oncology and radiology
    • Documentation of design and construction of Multi-Leaf Collimator
    • Detailed itemized bill and supporting documentation of all billed services
    • Documentation of treatment plan, including goals, treatment notes, specific dose constraints for the target and administration
  • Ensure the service was provided per the coverage guidelines for the service

HHS Releases National Cancer Plan

On April 3, 2023, the U.S. Department of Health and Human Services (HHS) released a National Cancer Plan, developed by the National Institutes of Health’s (NIH) National Cancer Institute (NCI) to support the Cancer Moonshot initiative.

The National Cancer Plan outlines a framework for the federal government as well as society as a whole to collaborate in the effort to end cancer. The plan was developed by the NIH and NCI in collaboration with the Cancer Moonshot, HHS, and representatives of the cancer community. It outlines eight essential goals and supporting strategies with the goal of preventing more cancers, reducing deaths, and improving the lives of everyone after a cancer diagnosis. The eight goals that aim to reduce the cancer death rate by at least half within 25 years include:

  • Prevent Cancer
  • Detect Cancers Early
  • Develop Effective Treatments
  • Eliminate Inequities
  • Deliver Optimal Care
  • Engage Every Person
  • Maximize Data Utility
  • Optimize the Workforce

Strategies to reach these goals include the pursuit of new cancer prevention vaccines, new imaging technologies for early detection, more aggressive and equitable treatments, and initiative to increase representation of all populations in cancer research.

“The National Cancer Plan represents a commitment to achieving a society where most cancers are prevented and where every person diagnosed with cancer lives a full and active life.”
NCI Director Dr. Monica M. Bertagnolli

Swallowable Capsule Monitors Radiation Dose During Radiotherapy

A collaboration between Shenzhen Institute of Advanced Technology (SIAT), the National University of Singapore (NUS) and Tsinghua University a swallowable capsule has been developed that can accurately monitor radiation dose during radiation therapy in real-time.

The x-ray dosimeter, measuring 5mm in diameter and 0.2mm, was found to measure radiation dose up to five times more accurately than standard methods. The dosimeter measures radiation dose based on radioluminescence, afterglow intensity and temperature.

The capsule could be particularly beneficial to patients receiving radiation therapy for gastrointestinal (GI) cancers and could be used to monitor treatment for different malignancies with further optimization of the capsule’s size. Thus far the capsule has been tested in GI tracts of rabbits.

“In the future, this capsule could be placed in the rectum for prostate cancer brachytherapy or in the upper nasal cavity for real-time measurement of the absorbed dose in nasopharyngeal carcinoma, minimizing radiation damage to surrounding structures,” said Professor SHENG Zonghai, one of the study’s authors.