Search
The approach will be used for medical services that are commonly subject to prior authorization, such as orthopedic surgeries and imaging services.
The pathway will allow the evidence generated for FDA review to support Medicare coverage decisions.
Cost control, Carelon integration and scaling AI are reasons for the company's confidence.
Fifty percent of the payment will be withheld to be reconciled after a 12-month care process, subject to two downward adjustments.
HHS is proposing to adopt certain HL7 FHIR standards and implement specifications for transactions related to prior authorizations.
The proposed rule would also make the Comprehensive Care for Joint Replacement (CJR) Model mandatory beginning on Oct. 1, 2027.
Aetna's policy results in denials and underpayment and violates CMS' Two Midnight Rule, the health system says.
The proposed payment increases of 2.3% for psychiatric care and 2.4% for rehab are lower than last year's final rule increases.
This compares with last year's final rate of 3.2%.
CMS proposed payment rule follows a call for new oversight of hospice provider fraud.
