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Episode 158: Slow and Steady, How Health Care is Progressing Toward Value Based Care. Lynn Carroll, HSBlox

August 22, 2023

A couple of new bills, or rather, retreads of old bills, demonstrate increased congressional interest in reforming prior authorization (PA) under Medicare Advantage (MA).

The Price Transparency bill’s Title III section (“Establishing Requirements with Respect to the Use of Prior Authorization Under Medicare Advantage Plans”) requires an “electronic prior authorization program” and “real-time decisions.”

Though similar in outline to the interoperability rule’s requirements, it is also vaguer about how these would be achieved, notes Robert Tennant, vice president, federal affairs for the Workgroup for Electronic Data Interchange (WEDI) in Washington, D.C.

For example, Tennant says, in its rule CMS “has proposed the Fast Healthcare Interoperability Resources (FHIR) standard that could result in real-time responses to some prior authorization questions.” The current bill largely avoids technical details.

Despite the bill’s vagueness, Tennant believes the introduction and reintroduction of the basic PA reform concepts in legislation is a good sign, and that the efforts to put these PA standards into law have emboldened CMS to go forward with its rule.

“I think this bipartisan, bicameral legislation signaled to CMS that there was interest on the Hill in solving prior authorization and that’s what led to the proposed rule and hopefully the final rule,” Tennant says.

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