News: CMS urged to simplify billing, prior approval processes

CDI Strategies - Volume 13, Issue 37

In response to a formal request for information (RFI) from industry stakeholders, CMS received 567 comments on ways to improve its Patients Over Paperwork Initiative, including many requests from hospital groups to simplify billing and prior approval requirements, JustCoding reported.

In the most recent RFI on the initiative, CMS invited patients and their families, the medical community, and other healthcare stakeholders to recommend further changes to regulatory, policy, practice, and procedural changes that were not conveyed during the first RFI in 2017.

In its commentary letter, the American Hospital Association (AHA) urged CMS to take the following actions to reduce medical billing burdens :

  • Align billing requirements with CPT codes to ensure that the CPT codes are billed for the same service regardless of the payer
  • Finalize its 2020 outpatient prospective payment system (OPPS) proposal to change the minimum required level of supervision from direct supervision to general supervision for all hospital outpatient therapeutic services
  • Minimize the use of temporary healthcare common procedure coding system (HCPCS) level II codes
  • Proactively identify HCPCS and Category III codes for complex new technologies
  • Rescind the OPPS requirement that the modifier for “drug amount discarded/not administered to any patient” is billed on certain Part B drug claims

According to the AHA, CMS can immediately implement these and other action items to reduce regulatory burdens affecting hospitals and patients, according to JustCoding.

The AHA, American Medical Association (AMA), and several other hospital groups also called for reforms to Medicare Advantage prior authorization requirements. Specifically, these groups commented that the process for obtaining prior approval is burdensome and can reduce patient access to care.

In its commentary letter, the AMA cites findings from a provider survey indicating that the majority of respondents wait at least one business day to receive prior authorization and that 28% of respondents reported a serious adverse event because of the prior authorization process. The AHA and America’s Health Insurance Plans also called on CMS to standardize the process for submitting and receiving prior authorization requests.

According to CMS, it has addressed or is in the process of addressing 83% of the actionable areas of burden identified through the 2017 RFI.

Editor’s note: This article originally appeared in JustCoding. To read the AHA’s letter, click here. To read the AMA’s letter, click here.

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