Current Procedural Terminology (CPT®) comprises nearly 11,000 five-digit alphanumeric descriptors which succinctly represent medical procedures. Whether employed for routine check-ups or complex surgeries, CPT codes are essential to medical documentation in the United States. CPT facilitates the exchange of information between healthcare professionals. It allows for the identification of trends in medical treatment, provides the basis for cost [...] Read More
On September 7th, the U.S. Department of Health and Human Services (HHS), through its Office for Civil Rights (OCR), issued the Discrimination on the Basis of Disability in Health and Human Service Programs or Activities proposed rule. HHS also issued a Fact Sheet and press release on the proposed changes. The goal of the rule [...] Read More
As the United States transitions from a fee-for-service (FFS) model of healthcare delivery to value-based payments (VBP), both payers and providers have recognized the importance of fairly accounting for preexisting differences in patient health status. The management of heart disease in a patient with diabetes and high blood pressure is inherently more complex and consequently [...] Read More
On August 1, the Centers for Medicare & Medicaid Services (CMS) issued the fiscal year (FY) 2024 Hospital Inpatient Prospective Payment Systems (IPPS) for Acute Care Hospitals and the Long-Term Care Hospital (LTCH) Prospective Payment System and Counting Certain Days Associated with Section 1115 Demonstrations in the Medicaid Fraction final rules. See the press release [...] Read More
Federal Administrative Law Judges (ALJs) exercise considerable authority in our national healthcare system. ALJs in the Food and Drug Administration routinely make adjudicatory decisions regarding drugs and medical devices. Those working within the Department of Labor may render decisions impacting a healthcare provider’s workforce or workplace. And the determinations of ALJs within the Drug Enforcement [...] Read More
On July 13th, the Centers for Medicare & Medicaid Services (CMS) issued the Hospital Outpatient Prospective Payment (OPPS) and Ambulatory Surgical Center (ASC) Payment Systems proposed rule, which proposes updates to the OPPS and the Medicare ASC payment system for calendar year (CY) 2024. See the press release here. CMS has provided a rule overview [...] Read More
In our series on prior authorizations, we have previously considered the administrative burden prior authorizations present for healthcare providers, as well as their potential to delay definitive care for individual patients. Here we examine prior authorizations within the context of health equity. There is increasing concern and growing evidence that the use of prior authorizations can [...] Read More
As the Centers for Medicare & Medicaid Services (CMS) has contracted with private health insurance plans for the provision of managed care options under the Medicare Advantage (MA) program, these plans have not unexpectedly brought commercial insurance’s utilization management practices to Medicare. Chief among these is prior authorization, the process under which health plans can [...] Read More
As noted last month, prior authorizations can be an important means of identifying clinically inappropriate or duplicative care. They are also increasingly employed as gatekeeping mechanisms to control healthcare spending by limiting utilization. This month, in the second installment of our conversation about prior authorizations, we examine how the U.S. healthcare system has given rise [...] Read More
Applied Policy has previously reported on the work of Recovery Audit Contractors (RACs), independent contractors sometimes characterized as “bounty hunters” for their pursuit of improper payments in the Medicare fee-for-service program. This month we turn our focus to a the “detectives” of the Centers for Medicare & Medicaid Services’ (CMS’s) program integrity activities—the unified program [...] Read More