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Prior Authorization: 5 Ways CMS Changes Could Open up Future Possibilities


The U.S. Centers for Medicare & Medicaid Services has proposed new requirements that would ease some of the administrative burdens of prior authorization across a range of federal programs including Medicare Advantage, state Medicaid and Children's Health Insurance Program fee-for-service plans, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan issuers in the federal ACA insurance exchange. Those changes, if adopted, would make life easier for providers, including PTs, almost immediately after their 2024 startup date.

But it’s broader than that. The proposed rules provide several opportunities for a more expansive conversation around prior authorization, transparency, and other aspects of administrative burden. That's yet another reason why it's crucial for APTA members and supporters to send comment letters to CMS by March 13.

Here are five ways the proposed rules — and even the comment process — could help the profession gain ground in other longer-term, big picture areas.

1. More Data = a Stronger Case (as Long as PTs Are Diligent About Appeals)

Under the proposed rules, prior authorization programs will be required to provide public data on their approval and denial rates, the rates at which they approve services after appeal, and average time frames for responding to prior authorization requests. Kate Gilliard, JD, APTA's director of health policy and payment, believes the increased transparency opens up some big opportunities.

"The new data requirements could lead to a couple of important outcomes," Gilliard said. "First, prior authorization plans could feel compelled to make better decisions, given that those decisions will become public. Second, the data will likely show policymakers just how bad things are, which could prompt more rulemaking to rein in these plans."

But, Gilliard points out, those changes aren't guaranteed — especially if providers are lax about pursuing denial appeals.

"The bottom line is, if no one appeals, then insurance companies think denials are an easy win and will do them more," Gilliard said. "Appeals would bring inappropriate practices to light under the proposed rule, and they're also an administrative burden for the insurance companies, and they don't like being weighed down with extra paperwork anymore than providers do."

2. If It Looks Like a Denial and Quacks Like a Denial …

The proposed rules' requirement for more public data has another upside: It could help to shed light on some plans' tendency to do an end run around what's effectively a denial by approving care for clearly insufficient durations and frequencies. Those micro-approvals in turn force PTs and other providers to make repeated requests for more care.

APTA says it's time for a reality check. In its comments to CMS, the association is pressing the agency to define a denial as anything less than what is requested by the clinician. APTA also is urging individual commenters to include that perspective in their own letters.

3. Let's Level the Interoperability Playing Field

CMS is proposing a new measure for clinicians to use in the Merit-based Incentive Payment System, or MIPS. Under the change, clinicians would be required to use electronic prior authorization to get MIPS credit under the Promoting Interoperability category, a category to which PTs don't have to report — yet. But CMS says that could change in 2024.

The problem is that the requirements for compliance as they now stand aren't a good fit for PTs. To meet MIPS standards, clinicians have to use certified electronic health records technology. Unfortunately, CEHRT is designed for prescribing professionals and doesn't adequately capture tasks performed by nonphysician professionals using different types of EHRs.

APTA is speaking up and urging its members to do the same in their comment letters on the proposed prior authorization rules: Tell CMS that if the agency intends to require PTs and nonphysician EHR vendors to fully participate in the interoperability parameters of MIPS, it needs to get everyone up to speed — either by lowering the CEHRT standards for nonphysicians or by providing funding for upgrades.

4. Prior Authorization Compliance Requirements Need Teeth

Under the proposed rules, prior authorization plans would be required to respond to prior authorization requests within seven calendar days — a welcome change. The problem? There's no penalty for plans that exceed the time limit.

"The only negative consequences for plans that don't meet prior authorization response deadlines is that they'll have to share that data publicly, but that's just not enough," Gilliard said. Instead, APTA has urged CMS to provide extra motivation for plans to comply: Mandate that plans approve any prior authorization request that doesn't receive a response within the required time frame.

5. It's Time to Think Big When It Comes to Admin Burden in Medicare

Perhaps feeling like it's on a roll, CMS is asking whether it should create prior authorization rules for Medicare fee-for-service plans similar to what's currently proposed. While it's never a bad idea to evaluate the appropriateness of prior authorization, the fact is that most PTs don't face prior authorization requirements under Medicare FFS. Gilliard sees that an opportunity for the profession.

"The conversation about prior authorization in Medicare is an excellent way for APTA and the profession to open up a bigger dialogue about administrative burden in all its forms," Gilliard said. "For PTs, prior authorization isn't the biggest challenge in traditional Medicare part B — it's the plan-of-care certification requirements. If CMS wants to look at prior authorization because it sees value in reducing administrative burden, this is another area worth looking at."

APTA's comment tip: Tell CMS that you appreciate that the agency wants to make Medicare FFS less burdensome, but suggest that the agency broaden its focus.

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Remote Therapeutic Monitoring: APTA Updates

While it's been more than a year since PTs were included in the list of providers able to bill for several remote therapeutic monitoring codes under the Medicare Physician Fee Schedule, details continue to be worked out — and possible changes discussed. APTA pursues those details and remains at the table for important conversations around what may or may not happen next.

Here's the latest on the PT's use of RTM under the fee schedule.

We've Updated the APTA Practice Advisory on RTM
In response to questions from members, APTA added more information to the practice advisory we published soon after the U.S. Centers for Medicare & Medicaid Services announced it would extend use of two sets of CPT codes related to RTM for use by PTs. The new information provides additional insight on billing requirements and PTA supervision.

We're Advocating for Continued Patient Access to RTM by PTs
APTA staff and member representatives participated in a recent Medicare Contractor Advisory Committee meeting to discuss the application of remote therapeutic monitoring in physical therapist practice. Generally speaking, these committee meetings are intended to be a platform for communication between providers and Medicare contractors; the Feb. 28 meeting was focused on soliciting input from subject matter experts about the use of physiologic monitoring and RTM. The aim of the meeting: To find out if it would be a good idea to establish a local coverage determination for these services. APTA made the case for no LCD, with our representatives sharing the association’s position that an LCD could interfere with patient access to these important services. APTA will submit comments as a follow-up to the call.

We're Working to Clear up Confusion Among MACs Around RTM Codes
APTA is communicating with Medicare Administrative Contractors — aka MACs — to address an apparent error in claims processing related to denials of services that should be covered. Specifically, since Jan. 1, 2023, when facilities have submitted claims for RTM on a UB-04 claim form, the MACs have accepted claims for codes 98975, 98976, and 98977 but denied codes 98980 and 98981, asserting that they're non-covered services. This is incorrect. APTA reached out to the MACs and is working with a representative from the Critical Inquiries Unit to address the error. APTA staff will provide updates as available.


What’s in Biden’s Budget

CNN | By Katie Lobosco and Tami Luhby
President Joe Biden released his annual budget Thursday, outlining his policy priorities for the year ahead.
Make no mistake, the proposed budget has no chance of making it through the Republican-controlled House. But Biden’s plan will frame upcoming political battles on Capitol Hill, where the GOP has yet to unveil its own spending plan.
Biden’s budget comes out after the US hit the debt ceiling, a cap set by Congress, earlier this year. The Treasury Department is now taking extraordinary measures to allow the government to keep paying its bills. But the country could start to default on its obligations over the summer if Congress doesn’t address the debt ceiling before then. Republicans are calling for some spending cuts in exchange for voting to raise the cap, while the White House does not want to negotiate on resolving the debt limit drama.
 Many of the provisions in the budget rehash the president’s earlier proposals to expand the social safety net and to pay for it by raising taxes on the wealthy and corporations. He wants to restore the expanded child tax credit and make permanent enhanced Obamacare subsidies, both enacted in the American Rescue Plan in 2021. And he wants to provide universal free preschool, make college more affordable and establish a national paid family and medical leave program, which did not make it into prior packages when the Democrats controlled Congress over the past two years.
Biden’s spending plan also calls for shoring up Medicare and capping the price of insulin for all Americans.
The administration says these proposed policies will result in a nearly $3 trillion reduction in the deficits – the difference between what the government spends and its revenue – over the next decade.
Here’s what’s in Biden’s budget proposal

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HHS Releases Initial Guidance for Historic Medicare Drug Price Negotiation Program for Price Applicability Year 2026

For the first time in history, Medicare will have the ability to negotiate lower prescription drug prices because of the Inflation Reduction Act, President Biden’s historic law which lowers health care and prescription drug costs. Today, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), issued initial guidance detailing the requirements and parameters—including requests for public comment— on key elements of the new Medicare Drug Price Negotiation Program for 2026, the first year the negotiated prices will apply. Alongside other provisions in the new drug law, the Medicare Drug Price Negotiation Program will strengthen Medicare’s ability to serve people currently in Medicare and for generations to come.

“For far too long, millions of Americans have had to choose between their prescription drugs and other monthly expenses,” said HHS Secretary Xavier Becerra. “President Biden is leading the fight to lower the cost of prescription drugs – and with the Inflation Reduction Act, we’re making historic progress. Through the Medicare Drug Price Negotiation Program, we will make sure seniors get a fair price on Medicare’s costliest prescription drugs, promote competition in the market, and ensure Medicare is strong for beneficiaries today and into the future.”

“Drug price negotiation is a critical piece of how this historic law improves the Medicare program,” said CMS Administrator Chiquita Brooks-LaSure. “By considering factors such as clinical benefit and unmet medical need, drug price negotiation intends to increase access to innovative treatments for people with Medicare.”…

View a fact sheet - PDF on the Medicare Drug Price Negotiation Program Initial Guidance

Read the Medicare Drug Price Negotiation Program Initial Guidance - PDF

Read the Full Press Release


Who is Most at Risk for Long COVID?

A new study of more than 800,000 people has found that in the U.S., COVID "long haulers" were more likely to be older and female, with more chronic conditions than people in a comparison group who—after getting COVID—did not have diagnosed long COVID or any of the symptoms associated with long COVID. The findings are published in the March issue of Health Affairs.

The national study, which focused on people with private insurance or Medicare Advantage coverage, aims to inform public health and clinical care by advancing the understanding of who gets long COVID.

As one of the largest studies of long COVID in the U.S. to date, in terms of the number and diversity of people studied and the length of time symptoms and diagnoses were followed, the study solidifies many previous insights about the demographics and clinical profile of people most likely to get sick.

It also provides new information to consider about the complex interaction of COVID-19 in patients with previously diagnosed chronic illnesses.

"This work in a large population helps to address the question of who is more at risk of long COVID," said Zirui Song, associate professor in the Department of Health Care Policy in the Blavatnik Institute at Harvard Medical School, lead author of the article.

"This may help clinicians and health care organizations screen, monitor, and treat patients more effectively. It may also help individuals, who know their own medical history, better assess their risk of long COVID and the value of protecting against getting COVID-19 in the first place," Song said.

The study's findings also indicate that symptoms of long COVID can appear or persist much longer after initial infection than many previous studies had suggested.

Most earlier work showed a peak of long COVID symptoms and diagnoses within the first six months of a person's initial COVID-19 diagnosis, the authors note, but the new research shows another, smaller peak around one year, which the authors note was significantly longer than the follow-up period of most initial studies.

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