The Healthcare Common Procedure Coding System (HCPCS, pronounced “hix-pix”) maintained by the Centers for Medicare & Medicaid Services (CMS) comprises two medical code sets, HCPCS Level I and HCPCS Level II. Level I consists of the Current Procedural Terminology© (CPT), a classification index which, as Applied Policy has previously discussed, is developed, maintained, and copyrighted [...] 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
The American Academy of Professional Coders (AAPC) held its highly anticipated national conference, HEALTHCON 2023, in Nashville, Tennessee, May 22-24. The event attracted a wide range of professionals from the healthcare industry. Applied Policy’s April Gutmann and Meghan Basler, attended the conference to gain valuable insights into billing and coding practices across different payment systems [...] Read More
Step therapy is the process under which a health insurance plan requires a patient to try one or more alternative—typically lower cost— drugs or treatment options before they can access the prescription which their physician has identified as the optimal treatment option for their diagnosis. For AHIP, the association representing America’s health plans, the stepwise [...] 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
On April 17, 2023, the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) issued the final Notice of Benefit and Payment Parameters for 2024. See the Press Release here and the Fact Sheet here. In a statement, HHS Secretary Becerra said that “[t]he Biden-Harris Administration has [...] Read More
Healthcare spending in the United States is expected to surpass $4.7 trillion in 2023. As Applied Policy has previously reported, some of that money may be spent on unproven, ineffective, unnecessarily expensive, or even harmful practices. Some of it will be spent on effective treatments for which there are less expensive alternatives. Some of it [...] Read More
On April 10th, 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 proposed rule. See the press release here. CMS released a fact sheetaccompanying the rule. The rule proposes to: increase [...] Read More
On April 5, 2023, the Centers for Medicare & Medicaid Services (CMS) released its Medicare Program; Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly (CMS-4201-F) with a fact sheet and press release. The final [...] Read More