Health Plans Commit to Improving Prior Authorization. Following a roundtable meeting hosted by the U.S. Department of Health and Human Services (HHS), approximately 50 health plans nationwide announced their commitment to six key actions to improve the prior authorization (PA) process for commercial plans, Medicare Advantage, Medicaid Managed Care, and Health Insurance Marketplace. The participating health plans have pledged to: (i) Standardize electronic PA requests with Fast Healthcare Interoperability Resources (FHIR®)-based application programming interfaces; (ii) Reduce the number of medical services subject to PA by January 1, 2026; (iii) Accept PAs in place for a period of time when patients change insurance; (iv) Improve transparency and communication of PA decisions and appeals; (v) Increase real-time responses by 2027; and (vi) Ensure health care clinicians review all denials. The goal of this effort is to streamline the PA workflow, accelerate care decisions, and enhance transparency for patients and providers. Additional details about the commitment were released by AHIP.
MHDC and ZeOmega Partner to Automate PA and Clinical Data Exchange in Massachusetts. The Massachusetts Health Data Consortium (MHDC) announced its partnership with ZeOmega, Inc. in launching a statewide network aimed at automating PA and enhancing clinical data exchange. This collaboration will streamline administrative processes and improve quality measurement across health plans and providers throughout Massachusetts. The solution leverages ZeOmega's technology to reduce delays in care, minimize manual data entry, and support real-time data sharing between payers and providers. The new initiative also expands MHDC's longstanding New England Healthcare Exchange Network (NEHEN) service and enhances NEHEN’s capabilities by integrating Fast Healthcare Interoperability Resources (FHIR) application program interfaces to support a single connection for real-time, automated PA and clinical data exchange. In addition, the upgraded platform will support a FHIR-based version of MHDC's Quality Measurement Specification, significantly improving how clinical data is shared and leveraged for quality measurement and reporting across the state.
Survey Open for Participation in 2025 CAQH Index. Data collection for the 2025 CAQH Index is now open for industry participation through August 15. Data contributions from medical and dental health plans, providers, and vendors are vital to the success of the CAQH Index. Data received through the survey allows CAQH to assess the progress of administrative automation and identify potential cost savings from full adoption. Organizations that complete the survey will receive a customized report comparing their results to the national findings. WEDI serves on the CAQH Index Advisory Council.
Senate Bill Addresses Payment of Algorithm-Based Health Care Services. The bipartisan Health Tech Investment Act, if enacted, will establish payment of certain algorithm-based health care services under the Medicare program. The bill calls for the assignment of these services to a new technology ambulatory payment classification (APC) based on the cost of the service, including the technology costs. That assignment will remain until there is adequate claims data to inform the reassignment to another APC or for at least 5 years. The bill defines algorithm-based health care services as ones that use artificial intelligence (AI), machine learning, or other similar software delivered through a device cleared or approved by the Food and Drug Administration that produces clinical conclusions for use by a provider in the delivery of health care.
ASTP Publishes USCDI v3.1. The Assistant Secretary on Technology Policy (ASTP) released U.S. Core Data for Interoperability (USCDI) v3.1. The Sex, Sexual Orientation, and Gender Identity data elements have been removed or updated in the Patient Demographics/Information Data Class, to meet Executive Order 14168. Additional information is available in the USCDI v3.1 Standard Document.
ASTP/ONC Releases Electronic Prescribing Beta Testing Tool. The ASTP/Office of the National Coordinator for Health Information Technology (ONC) released a beta testing tool for the National Council for Prescription Drug Programs SCRIPT Standard Version 2023011 updates. The testing tool will be available until December 31, 2025. ASTP/ONC is also encouraging users of the tool to submit feedback in a dedicated beta testing Google Group.
ASTP Updates Standards Implementation & Testing Environment. ASTP made several updates to its Standards Implementation & Testing Environment (SITE) to improve the functionality and fix reported issues. ASTP recommends that users verify that they have downloaded the current versions before using the services again. Any issues identified can be reported to the Google Groups page.
BPC Releases Report on Federal and State Oversight of AI. A report from the Bipartisan Policy Center (BPC) reviews and summarizes federal and state legislative and regulatory oversight of the use of AI that is not regulated by the Food and Drug Administration (FDA). Health care functions not generally regulated by the FDA include revenue cycle management, scheduling, clinical and care management, and wellness (i.e., fitness and health applications). The report can assist developers and users understand requirements when implementing AI tools.