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CMS has a new regulation regarding pre-authorization in fed med and those plans sold on Ocare platforms. The insurers now must send decision for expedited requests in 72 hours and within 7 calendar days for routine requests. They must provide a specific reason for any denial. This does not apply for drug pre-authorizations. The insurers must also standardize the process using an electronic prior authorization programming interface. The rule did not address the volume of prior authorizations practices must perform daily. There was no mention of when this goes into effect.
The Biden administration continues on a downward spiral regarding abortion and EMTALA. The administration continues to state that EMTALA requires emergency abortion and the courts say that this is not so. The physicians will continue to be caught in the middle until the Supreme Court decides the issue.
New Jersey has enacted a comprehensive law regarding prior authorization. It says that if a prior authorization is denied it must be done by a physician in the same specialty as the one requesting the approval. If a patient received a prior authorization from a prior health plan the new plan must honor that for at least 60 days until the new approval is obtained. Patients receiving hospital treatment must get a response within 24 hours and those with urgent care must get a response in 72 hours. Plans must list on their websites how many denials they have issued and the reasons why along with other information.
DISCLAIMER: Although this article is updated periodically, it reflects the author's point of view at the
time of publication. Nothing in this article constitutes legal advice. Readers
should consult with their own legal counsel before acting on any of the
information presented.