Reimbursement
Patient care is a holistic solution as getting prior authorization doesn't help the patient who can't afford the medication, says Brian Smith, chief pharmacy officer at Shields Health Solutions.
The approach will be used for medical services that are commonly subject to prior authorization, such as orthopedic surgeries and imaging services.
The goal is to streamline the time for payers to approve prior authorizations, for patients to get their care and for providers to get paid, says Lalithya Yerramilli, SVP of Payment Solutions for Cohere Health.
The core issue is a structural mismatch between what it takes to run a primary care practice, versus what the system pays for it, says Elation Health's CEO.
Insurers can expect shrinkage in the individual market and a deterioration in the risk pool, says Wakely report.
Fifty percent of the payment will be withheld to be reconciled after a 12-month care process, subject to two downward adjustments.
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.
CMS proposed payment rule follows a call for new oversight of hospice provider fraud.