Cara Tucker, Legal Counsel, Author at Ensemble Health Partners https://www.ensemblehp.com/blog/author/cara-tucker/ Your modern revenue cycle solution Mon, 10 Nov 2025 21:18:33 +0000 en-US hourly 1 https://www.ensemblehp.com/wp-content/uploads/2023/10/Logo-Chevron-80x80.png Cara Tucker, Legal Counsel, Author at Ensemble Health Partners https://www.ensemblehp.com/blog/author/cara-tucker/ 32 32 The WISeR Model: Using AI in a New Era of Prior Authorizations for Medicare https://www.ensemblehp.com/blog/the-wiser-model/ Wed, 05 Nov 2025 19:11:52 +0000 https://www.ensemblehp.com/?p=20165 The Wasteful and Inappropriate Service Reduction (WISeR) Model introduces prior auths for select services at risk of fraud, waste and abuse. … Read More

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November 10 update: Since this article was published, CMS has shared key details of the WISeR Model that were previously pending. On the evening of Nov. 6, CMS revealed the technology companies selected as Model Participants — companies that will use enhanced technology like artificial intelligence to support medical necessity coverage determinations. These companies include Cohere Health, Inc., Genzeon Corporation, Humata Health, Inc., Innovaccer Inc., Virtix Health LLC and Zyter Inc. The following day, Democrats in the U.S. House of Representatives introduced legislation to repeal the model. With the January 1 effective date approaching, Ensemble will continue to monitor these developments as our operators prepare our clients for success under the model.

The Centers for Medicare & Medicaid Services (CMS) is launching the Wasteful and Inappropriate Service Reduction (WISeR) Model on January 1, 2026 — a bold, six-year initiative designed to tackle fraud, waste and abuse (FWA) in Medicare Fee-for-Service (FFS) by using advanced technologies — artificial intelligence (AI) and machine learning (ML) — to introduce prior authorization for select services at higher risk of FWA in certain selected states.

This model arrives at a critical moment where there’s heightened industry interest in incorporating AI into workflows along with heighted Federal interest in reducing FWA spending generally across the government. Its importance to FWA is further highlighted by a September 2025 Health and Human Services (HHS) Office of Inspector General (OIG) report, which found that Medicare Part B spending on one of the targeted services, skin substitutes, exceeded $10 billion in 2024, with alarming trends in utilization, pricing and fraud schemes.

The model, however, faces practical and political obstacles to its January 1 launch date. Practically, key details about the program remain unknown, and the ongoing government shutdown likely delays final decisions and communications about it from CMS.

Politically, several members of Congress have criticized WISeR, warning that its AI-driven prior authorization process could delay or deny necessary care for Medicare beneficiaries. Lawmakers argue the model threatens patient access and mirrors problematic practices in Medicare Advantage. A House resolution was introduced in September to halt the model, followed by a proposed amendment to the HHS funding bill to block funding of the model. The status of this opposition remains unresolved during the ongoing government shutdown. The American Hospital Association also recently voiced its concerns with the model and urged CMS to delay its launch by six months.

What is the WISeR Model?

WISeR is a CMS Innovation Center initiative focused on reducing unnecessary and inappropriate services in Medicare FFS by using AI and ML to streamline prior authorization (PA) and medical review processes for items and services vulnerable to FWA, such as skin substitutes, electrical nerve stimulators and knee arthroscopy for osteoarthritis.

WISeR’s implementation is driven by the vulnerability of certain Medicare services to FWA, rising concerns of overuse and patient safety. With significant wasteful spending — up to 25% of U.S. healthcare costs per CMS — and documented fraud in areas like skin substitutes, CMS seeks to leverage AI and ML to modernize oversight and ensure care is both clinically beneficial and safe for patients while also ensuring payment complies with Medicare rules.

WISeR is not a mandatory model for Medicare providers in the selected states of Arizona, New Jersey, Ohio, Oklahoma, Texas, Washington. Providers in these states will have the option to submit a prior authorization request or go through a post-service/pre-payment review. WISeR does not change Medicare coverage or payment policy.

How does WISeR work?

  1. Model Participants: Companies selected by CMS with expertise in AI and ML tech-enabled PA will perform reviews and issue a prior authorization decision (affirmation or non-affirmation) of the requested procedure. Non-affirmation decisions require the review of a licensed clinician prior to issuance. The Model Participants’ compensation is controversially tied to the amount of savings associated with their denials. These AI vendors have not yet been announced by CMS.
  2. Targeted services: WISeR identifies high-cost, high-risk Medicare Part B services for review, including skin and tissue substitutes, electrical nerve stimulators, knee arthroscopy and more. Excludes inpatient, emergency and risky delayed services.
  3. Provider participation: As previously stated, the model is optional, so providers in selected states (Arizona, New Jersey, Ohio, Oklahoma, Texas, Washington) can choose to submit PA requests for targeted services or proceed with rendering the services understanding the claim will undergo pre-payment review.
  4. Submitting a prior authorization request: Providers in designated regions who choose to submit a PA request will submit supporting documentation for the targeted service to either their regional MAC with the MAC routing to the Model Participant or directly to the Model Participant who will then use AI and ML tools to perform its review to make a coverage decision.
  5. Decision issued: The Model Participant notifies the provider of its decision to affirm or not affirm the service. If affirmed, the Model Participant will provide a unique tracking number to inform a payment determination when the claim is submitted. If not affirmed, the provider may either resubmit its request (unlimited opportunities to do this) or request a peer-to-peer review.
  6. Gold Carding: Providers with demonstrated records of compliance may receive exemption from PA requirements, subject to compliance monitoring.
  7. Safeguards: All data sharing is HIPAA-compliant, and the appeals process remains unchanged for denied claims.
  8. Medicare coverage and payment policies remain the same. WISeR does not change Medicare coverage or payment policy.

How is Ensemble addressing WISeR's implications for providers?

The WISeR Model has key implications for providers:

  1. Providers in the selected states must choose whether to adopt these new PA processes or risk claims for targeted services being pended for pre-payment review or potentially denied.
  2. High performers may benefit from reduced administrative burden through gold-carding.

WISeR represents a pivotal shift in CMS oversight by introducing prior authorization requirements to Medicare FFS services. For CFOs and financial leaders of healthcare providers, proactive engagement with WISeR’s design and opportunities will be key to driving success with the model’s requirements.

At Ensemble, we are actively working to position our clients for success under WISeR. For states impacted by WISeR where we have a client footprint, we are focusing on identifying impacted procedures, engaging vendor partners and building automation into prior authorization workflows. Our teams are currently mapping these areas and initiating discussions with vendors to align planning and next steps.

This approach ensures that when CMS announces approved AI vendors (i.e., Model Participants), we will be ready to integrate prior authorization processes quickly and effectively, so as to avoid pre-payment medical reviews and potential denials. This approach also positions our clients for success in qualifying for gold-carding.

Our goal is to automate as much as possible across all client platforms. In this way, we can reduce administrative burden and accelerate approvals through configuration of existing systems, streamlined routing logic for documentation and integration with external authorization solutions and approved CMS vendor solution partners.

By acting now, we aim to ensure our clients are prepared, compliant and positioned to leverage automation for efficiency and cost savings under the WISeR Model.

For more information:

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]]> Tracking Potential State Regulation of Artificial Intelligence in Healthcare https://www.ensemblehp.com/blog/tracking-potential-state-regulation-of-artificial-intelligence-in-healthcare/ Tue, 01 Apr 2025 20:28:24 +0000 https://www.ensemblehp.com/?p=17758 Shifts in federal policy may lead to more activity at the state level. Here some state bills seeking to regulate the use of AI in healthcare. … Read More

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On his first day in office, President Trump revoked former President Biden’s Executive Order 14110. Issued October 30, 2023, this now-revoked EO sought to promote certain principles regarding the development, use, safety and security of AI.

In its place, President Trump issued EO 14179. Titled Removing Barriers to American Leadership in Artificial Intelligence, this EO seeks to broadly deregulate AI at the federal level and shift the policy of the United States to “global AI dominance.” This shift in federal policy may lead to more activity at the state level to regulate the development and use of AI.

Ensemble is tracking the state legislative sessions of our full outsource partners across the country. Below are some state bills that we’ve identified so far this year seeking to regulate the use of AI in healthcare.

As it relates to use of AI by insurers, legislative trends include prohibitions against use of AI without any human oversight, particularly with respect to determinations of medical necessity, and a focus on the prevention of patient discrimination.

Connecticut

Legislators in the Connecticut House have proposed two house bills which would restrict health insurers’ use of artificial intelligence in the denial of health insurance claims:

Connecticut Senators have proposed similar bills:

  • Proposed S.B. No. 817 would prohibit health insurers from using AI, or a similar tool or algorithm, to automatically downcode or deny a health insurance claim submitted by a healthcare provider without detailed review by a clinical peer.
  • Proposed S.B. No. 447 would prohibit health carriers from using AI in the evaluation and determination of patient care to safeguard patient access to testing, medications and procedures.

Lastly:

  • S.B. No. 2 seeks to broadly protect consumers from the risk of algorithmic discrimination and unfair treatment posed by AI.

The most recent version of this bill (S.B. No. 2) indicates its requirements would apply when AI is used to make, or is a substantial factor in making, a “consequential decision” which is defined as including any decision which has a significant effect on the provision or denial of healthcare services to a consumer.

In such cases when the consequential decision is adverse, there must be disclosures to the consumer and opportunities to examine the personal data used by AI to make the decision and correct it as needed. There may also be an opportunity to appeal where that personal data was inaccurate.

As currently written, this law would exempt covered entities to the extent that they are providing healthcare recommendations that (A) are generated by AI, (B) require a healthcare provider to take action to implement such recommendations, and (C) are not considered to be high risk.

Florida

In Florida, one related bill was introduced recently in March:

  • SB 794 would require insurers generally to ensure that any decision to deny a claim is reviewed, approved and signed off by a “qualified human professional.” It would prohibit the use of AI, an algorithm or an automated system as the basis for determining whether to deny a claim. The qualified human professional would be required to analyze the facts of the claim and the terms of the insurance policy independently of AI and to review the accuracy of any output generated by AI.

Insurers would be required to keep documentation of the basis for the denial and to identify the qualified human professional who reviewed the denial decision in all communications to the claimant.

Illinois

Illinois has the Artificial Intelligence Systems Use in Health Insurance Act (SB1425):

  • SB1425 proposes providing for regulatory and enforcement oversight of health insurers’ use of AI systems when those systems are used to make or support adverse determinations.

Regulatory review would include, for example, investigations and market conduct actions regarding health insurers’ development, implementation, and use of AI systems. This Act would also prohibit health insurers from using AI exclusively when it comes to denying or reducing benefits. Where AI is used in any decision-making process for that adverse determination, the Act would require meaningful review by an individual with authority to override the AI system’s determinations. Lastly, this Act would require health insurers to disclose their AI system utilization.

On the provider side in Illinois:

  • SB2259 would amend the Medical Practice Act to require hospitals and providers that use generative AI to generate written or verbal patient communications pertaining to patient clinical information adhere to certain criteria and that such communications be read and reviewed by a licensed provider.

Indiana

In Indiana:

  • HB 1620 proposes requiring both healthcare providers and insurers to disclose the use of AI technology to the patient or insured

(1) when it’s used to make or inform any decision involving the patient or insured, or

(2) when it’s used to generate any part of a communication to the patient or insured.

Tennessee

In Tennessee:

  • SB 1261/HB1382 proposes requiring health insurance issuers using AI (or algorithm or other software tool) for utilization review or management ensure that AI bases its determinations on:
  1. An enrollee’s medical or clinical history
  2. Individual clinical circumstances presented by the requesting provider
  3. Other relevant clinical information in the enrollee’s medical record

Health insurance issuers would be required to ensure that the AI does not supplant the healthcare provider’s decision-making, discriminate or directly or indirectly cause harm to the patient. It also proposes prohibiting AI from denying, delaying or modifying healthcare services based on medical necessity.

Instead, such determinations may only be made by a licensed physician or a licensed healthcare professional competent to evaluate the patient’s specific clinical issues involved and the services requested by the patient’s provider.

New Mexico

In New Mexico:

  • HB 60, the Artificial Intelligence Act, seeks to require AI developers to protect consumers from algorithmic discrimination. Deployers, or users, of AI systems making a “consequential decision” (defined as including any decision affecting the provision or denial of healthcare services) would be required to implement policies and programs to protect consumers from foreseeable risks of algorithmic discrimination.

In addition to providing consumers with general notice of their AI use, deployers would also be required to provide direct notice and opportunity for appeal to consumers when AI is used to making adverse consequential decisions.

Taken together, this bill may impose new requirements on health insurers using AI in their decision-making concerning the provision or denial of healthcare services to their members.

Texas

The Texas Legislature meets every two years, so there is a bit more activity in this state.

  • HB 1709, The Texas Responsible Artificial Intelligence Governance Act, seeks to comprehensively and broadly regulate the development and use of AI with respect to “consequential decisions,” defined as including those decisions involving a healthcare service or treatment.
  • SB 815/HB 2922 would prohibit utilization review agents from using automated decision systems (defined as an algorithm that may be incorporating AI) to make, wholly or partly, adverse determinations. The House bill prohibits the sole use of automated decision systems and would further require that determinations about medical necessity or the appropriateness of healthcare services be made by a physician or licensed healthcare provider.  
  • SB 1822/HB 4018 would require health insurers and health maintenance organizations to disclose to its insureds and contracted providers whether it uses AI in conducting utilization review. It would also require that any AI used minimizes the risk of bias and complies with evidence-based clinical guidelines.
  • SB 1411 would require health benefit plan issuers to disclose its use of AI in utilization review to members and contracted healthcare providers. This bill would also require submission of AI-based algorithm and training data sets used in utilization review to the Texas Commissioner for Insurance, and that a healthcare provider be involved in the utilization review that uses AI. This bill would also establish certain oversight and enforcement authority of its requirements.

The bottom line

Many of these proposed state regulations aim to prohibit the use of AI without any human oversight. This is a safeguard we support to ensure the ethical, effective application of AI in healthcare.

We believe AI with human oversight has the power to eliminate administrative barriers standing between patients and providers. Ensemble’s approach to AI aims to:

  • Reduce the time and energy spent on administrative tasks by clinicians and staff to mitigate burnout and be more responsive to patient needs and enable access to care. This includes automating routine and manual tasks and providing AI-powered intelligence to prioritize and provide next best action recommendations. This enables providers to tackle more complex tasks in areas including insurance collections and appeals.
  • Reduce denials, expedite patient access to care and accelerate accurate reimbursement by identifying billing issues, preventing denials and automating the appeals process.
  • Improve the patient experience by reducing call wait times and resolve patient needs faster by transcribing calls so human operators can focus on addressing patient needs instead of taking notes.

Our experts will continue to track proposed legislation that impacts the use of artificial intelligence in the healthcare sector. We are committed to sharing this information — as well as information around our continued efforts to put AI to use for the benefit of providers.

These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Neither Ensemble Health Partners, nor any of its employees, are your lawyers. Please consult with your own legal counsel or compliance professional regarding specific legal or compliance questions you have.

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]]> Whistleblower Program Incentivizes Reporting of Healthcare Fraud https://www.ensemblehp.com/blog/whistleblower-program-incentivizes-reporting-of-healthcare-fraud/ Mon, 30 Sep 2024 14:18:38 +0000 https://www.ensemblehp.com/?p=14953 A new corporate whistleblower program incentivizes reporting of healthcare fraud involving private insurance plans. … Read More

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A new corporate whistleblower program incentivizes reporting of healthcare fraud involving private insurance plans. Under its statutory authority to pay awards for information or assistance leading to civil or criminal forfeiture, the Criminal Division of the United States Department of Justice (DOJ) recently launched the Corporate Whistleblower Awards Pilot Program to “uncover and prosecute corporate crime.”

This program establishes a new mechanism to identify corporate criminal and civil wrongdoing by whistleblowers as such conduct, as explained by the DOJ, “might otherwise go undetected or be difficult to prove.”

It targets four main subject areas, one of which includes healthcare fraud schemes involving private health insurance plans including fraud against patients, investors and other non-governmental entities in the healthcare industry.

What makes this program unique?

As explained by the DOJ in the FAQ, this whistleblower program fills the gap between fraud involving federal healthcare programs (e.g., Medicare and Medicaid) under the False Claims Act (FCA) qui tam provisions and fraud schemes involving private or other non-public healthcare payers where qui tam does not apply. Unlike the FCA’s qui tam provision, however, this program applies to both criminal and civil acts.

Whistleblowers would need to provide, in writing, original information (as defined in the program) to the DOJ. Where the original information provided leads to a net forfeiture of more than $1 million, the whistleblower may be eligible for an award according to the DOJ’s discretion.

The DOJ’s discretionary criteria indicate that DOJ wishes to first incentivize whistleblowers to report their concerns about potential violations through their internal whistleblower, legal or compliance procedures. Doing so and assisting with their company’s internal investigation are factors DOJ considers for increasing the whistleblower’s award.

Conversely, whistleblowers unreasonably delaying their reporting of potential violations, or interfering with internal compliance and reporting systems, are factors DOJ considers for decreasing the amount of the award.

In its FAQ, the DOJ further explained that this program “complements and strengthens DOJ’s existing “voluntary self-disclosure” (VSD) programs, which offer companies and individuals potential benefits when they self-report their misconduct, remediate the harm, identify responsible individuals and fully cooperate with the government’s investigation.” The DOJ wants to incentivize companies to self-disclose misconduct as soon as they learn of it.

What are the implications for healthcare providers?

Ensure your organization has:

  • Sufficient controls and audit practices in place to identify potentially fraudulent activity for private or other non-public healthcare payers in addition to federal healthcare programs
  • A robust compliance program with whistleblower protections, including non-retaliation policies, and that such programs include prompt and meaningful investigations of reported concerns with follow-up to the whistleblower

For more information on how an effective compliance program should be structured, review the General Compliance Program Guidance issued by the Department of Health and Human Services (HHS) Office of Inspector General (OIG) in November 2023.

Among the seven elements of a compliance program, HHS OIG recommends there be appropriate training and education of requirements and that there be effective lines of communication between the compliance officer and entity personal to reduce the potential of fraud, waste and abuse. Having these measures in place across your organization for all types of payers will reduce your organization’s risk for criminal or civil forfeiture under this new program.

Lastly, if your internal investigation discovers problematic conduct involving private health insurance plans, then the DOJ’s temporary amendment to its Criminal Division’s Corporate Enforcement and Voluntary Self-Disclosure Policy (CEP) allows companies who receive a whistleblower’s report internally to qualify for the presumption of a declination under certain conditions. In such cases, review with your legal counsel to determine your next steps.

Learn more

For more information on the DOJ’s Corporate Whistleblower Awards Pilot Program, visit the DOJ’s website devoted to this new program. See also the associated Fact Sheet and Guidance.

These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Neither Ensemble Health Partners, nor any of its employees, are your lawyers. Please consult with your own legal counsel or compliance professional regarding specific legal or compliance questions you have.

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]]> CMS Tightens Prior Authorization Time Frame in Final Rule https://www.ensemblehp.com/blog/prior-authorization-time-frame-cms/ Tue, 30 Jan 2024 19:50:13 +0000 https://www.ensemblehp.com/?p=12621 Health plans will be required to meet a prior authorization time frame as short as 72 hours, along with providing reasoning for any denials. … Read More

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What you need to know

Certain types of health plans will be required to provide decisions on prior authorizations within 72 hours (for urgent requests) and seven calendar days (for standard requests), along with reasoning for any denials. These payers must also implement new APIs to streamline electronic prior authorization processes. Operational processes will take effect in 2026 with compliance dates in 2027. This is a welcome regulation in the American healthcare industry where 94% of physicians reported that prior authorization led to delays in patient care, and 46% said these policies led to urgent or emergency care.

The Centers for Medicare & Medicaid Services (CMS) recently released a final rule tightening the prior authorization time frame for certain plan types, including Medicare Advantage Organizations, Medicaid Fee-For-Service (FFS) and managed care programs, Children’s Health Insurance Program (CHIP) FFS and managed care programs, and Qualified Health Plan (QHP) issuers on the Federally Facilitated Exchanges (FFEs).

The CMS Interoperability and Prior Authorization Final Rule outlines new deadlines for prior authorization decisions, specifically 72 hours for urgent requests and seven calendar days for standard requests. Previously, these time frames for response could vary between different plan types and managed care plans.

New transparency provisions mean that impacted payers must also provide insights into:

  • Reasons for care denials: CMS will now require impacted payers to send notices to providers when they make a decision, including a specific reason for denial when they deny a prior authorization request.
  • Prior authorization programs as a whole: Aggregated metrics from each health plan must be publicly reported each year.

In addition to adhering to the new prior authorization time frame, impacted payers must also implement Prior Authorization, Patient Access, Provider Access, and Payer-to-Payer APIs. In an industry with an increasing focus on interoperability, these new standards go a long way toward facilitating communication and improving data-sharing for the benefit of patient care and treatment.

Impact: removing barriers to patient care

The final rule deals with the logistics of deadlines and technological interoperability, yet it is patients and providers who are intended to benefit the most. This is because the final rule’s main components are focused on standardization and transparency with the goal of reducing the burden of the prior authorization process.
The rule requires payers to provide:

  • Standardized decision timelines: The timeframes for response will encourage payers to better communicate and coordinate with their third-party vendors to whom they may outsource prior authorization decisions. These prior authorization time frames, combined with the requirement to provide a denial reason, will go far to relieve providers of existing burdens relating to chasing payers and their vendors for an answer and related reason.
  • Denial reasons: Providing a denial reason seems obvious, but payers too often do not offer any explanation for why a healthcare provider’s prior authorization request is denied. If anything, payers’ reasons are often conclusory statements and boilerplate text that do not speak to the specifics of their decision in relation to the individual patient’s care and treatment. Payer denials may also use proprietary codes or text, which burdens providers who are left with no option but to decipher a specific payer’s proprietary and inefficient method of communication.
  • Publicly reported metrics: CMS is requiring impacted payers to publicly report certain prior authorization metrics by posting them directly on the payer’s website or via publicly accessible hyperlink(s) on an annual basis. This will enhance transparency and understanding within the industry as to the effectiveness of these rules in promoting interoperability and improving prior authorization processes.

Limitations of the prior authorization time frame final rule

None of the new requirements apply to employer-sponsored health plans, which are the most common type of coverage in the United States, covering approximately 54% of the population. In response to comments, CMS said it encourages these types of plans to voluntarily meet the requirements of the final rule to allow patients they cover to have the same interoperable access to their data as those patients with coverage through impacted payers.

The requirements also do not apply to drugs of any type that could be covered by impacted payers. CMS explained that this is because the standards and processes for issuing prior authorization for drugs differ from those that apply to medical items and services.

Additionally, there are already existing regulations for some impacted payers which require prior authorization responses for drugs within certain timeframes. In the final rule, however, CMS said that it would consider options for future rulemaking to address improvements to the prior authorization processes for drugs.

Options around prior authorization time frame compliance

The requirements of this final rule are optimized towards patients’ and providers’ best interests but will only be as effective as the level of payer compliance. What if payers don’t adhere to the new rules or are otherwise inconsistent in their implementation?

As an initial matter, providers must be able to identify instances of payer noncompliance with these requirements. Identifying noncompliance may require new reporting, as well as effective education and training of utilization management and appeals teams. Training and education on the requirements must include how your organization intends to respond to noncompliance and hold payers accountable. This may include, for example, scripting for appeals.

If the noncompliance is not overturned on appeal, or it continues or is systemic, do providers have any sort of regulatory recourse? CMS addressed this question in the final rule, noting that many commenters expressed concern regarding the lack of a proposed mechanism to ensure compliance.

CMS said that its oversight and compliance procedures and processes vary among the different impacted payers, and CMS may consequently take different compliance and enforcement actions. Depending on the plan type, CMS said that patients and providers “may submit an inquiry or complaint to the appropriate authority.”

To effectively file a complaint for noncompliance with these requirements, providers will need to be able to identify the plan type and then the appropriate regulatory authority. This will vary, and Ensemble’s payer strategy team can help.

Encouraging provider + hospital adoption

To encourage provider adoption of electronic prior authorization processes, the final rule requires a new measure for Merit-based Incentive Payment System (MIPS) eligible clinicians under the Promoting Interoperability performance category of MIPS, as well as for eligible hospitals and critical access hospitals (CAHs) under the Medicare Promoting Interoperability Program.

The new measure will ask clinicians and hospitals to attest “yes” to requesting a prior authorization electronically through a Prior Authorization API during the Calendar Year 2027 performance period.

A better outcome for patients + providers

Existing processes are unsustainable. They unfairly and unnecessarily burden providers with the onerous task of navigating each payer’s prior authorization requirements from submission, data requirements and appeal of inappropriate denials.

The entire process wrongfully detracts limited and valuable resources away from patient care and contributes to provider burnout. It imposes a substantial financial burden on providers who must employ teams of individuals to assist in navigating the disparate prior authorization processes between payers. Most critically, these payer processes cause delays in patient care and treatment plans, which can directly lead to patient harm.

At Ensemble Health Partners, we fervently support the newly published final rule from CMS. Regulatory efforts to standardize, automate and streamline prior authorization processes help ensure patients receive timely access to necessary care and work to remove undue burden from healthcare providers.

These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Neither Ensemble Health Partners, nor any of its employees, are your lawyers. Please consult with your own legal counsel or compliance professional regarding specific legal or compliance questions you have.

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]]> Congress Investigates OIG Report That Medicaid MCOs Deny Prior Authorizations at Higher Rates https://www.ensemblehp.com/blog/oig-report-finds-medicaid-mcos-deny-prior-authorizations-at-higher-rates-is-new-rulemaking-on-the-horizon/ Tue, 03 Oct 2023 20:25:55 +0000 https://www.ensemblehp.com/?p=11809 A report from the OIG found some MCOs have unusually high rates of prior authorization denials, with limited or no state oversight. … Read More

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This article was originally published August 2023 and updated October 2023 to reflect latest developments.

Congressional leaders have launched a new investigation of the largest Medicaid Managed Care Organizations (MCOs) following an OIG report that raised concerns about MCOs increasing profits by denying requests for care.

Congress recently issued letters to Aetna, AmeriHealth Caritas, CareSource, Centene Corporation, Elevance, Molina Healthcare, and United Healthcare requesting documentation on a variety of topics, including:

  • Prior authorization requirements for Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services across its subsidiary health plans
  • A description of all algorithms used in prior authorization decisions separated by approvals, partial denials, and full denials
  • The rate of appeals by level of appeal and the outcome for Medicaid MCOs and for its Medicare Advantage products

This investigation follows on the heels of a July 2023 report from the Department of Health and Human Services (HHS) Office of Inspector General (OIG), which found that some Medicaid Managed Care Organizations have unusually high rates of prior authorization denials, and there’s limited or no state oversight of these denials.

Background: July Report Shed Light on Medicaid MCOs

Looking at 2019 data, OIG found that MCOs generally denied one out of every eight requests for prior authorizations. Among 115 MCOs reviewed, 12 had prior authorization denial rates greater than 25%—twice the overall rate.

For comparison, OIG noted the overall denial rate for Medicare Advantage (MA) plans was only 5.7% of requests in 2019. OIG stated the factors it reviewed “raise concerns that some people enrolled in Medicaid managed care may not be receiving all medically necessary health care services intended to be covered…”

CMS Updates to MA Plan Requirements

The Centers for Medicare & Medicaid Services (CMS) issued a Final Rule in April that requires MA plans to follow traditional Medicare laws for coverage decisions and limits the use of prior authorization, among other changes.

Ensemble Health Partners’ team of subject matter experts shared insight into these changes and their potential impact on providers.

For that Final Rule, CMS relied in no small part on an April 2022 report issued by OIG titled, “Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care.” Based upon that report, CMS issued new rules to act as guardrails to ensure MA plans use utilization management tools and make associated coverage decisions, in ways that ensure beneficiaries’ timely and appropriate access to medically necessary care.

OIG Recommendations + Potential Actions

In July 2023, the OIG issued a similar report, but this time examined the high rates of prior authorization denials by Medicaid MCOs. In its report, OIG recommended CMS require states to exercise more oversight over prior authorization denials through regular review of denial samples, required data reporting from MCOs, issuance of guidance and implementation of automatic requirements for external review. This could lead to future rulemaking from CMS to curb this behavior from Medicaid MCOs.

The OIG’s recommendations primarily focus on state oversight. However, it may be appropriate for additional rulemaking to require states to establish their own guardrails around MCOs. These guardrails would ensure prior authorization decisions align with state Medicaid standards for medical necessity and limit when MCOs may use their own internal coverage criteria to deny beneficiary access to care.

State Obligations + CMS Initiatives for Medicaid Beneficiaries

Under federal law, states must ensure all services covered under each state Medicaid plan are available and accessible to enrollees of MCOs in a timely matter. Federal law also requires contracts between a state and MCO to specify what constitutes “medically necessary services,” and be no more restrictive than what’s used by the state Medicaid program.

Acting on OIG’s recommendations and possibly taking these additional steps, CMS could ensure Medicaid beneficiaries have timely access to medically necessary services similar to its attempt to do for Medicare Advantage beneficiaries.

________________________________________

Cara Tucker has been an attorney for over 10 years, specializing in healthcare and regulatory compliance. She currently serves as legal counsel managing regulatory updates at Ensemble Health Partners, developing legally based strategies and procedures to holistically resolve systemic payor issues to increase revenue, reduce administrative burdens and mitigate risk for providers.

 

These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Neither Ensemble Health Partners, nor any of its employees, are your lawyers. Please consult with your own legal counsel or compliance professional regarding specific legal or compliance questions you have.

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]]> 2024 Medicare Advantage Program Changes: What You Need to Know https://www.ensemblehp.com/blog/2024-medicare-advantage-program-changes-what-you-need-to-know/ Tue, 18 Jul 2023 15:41:09 +0000 https://www.ensemblehp.com/?p=11374 This new rule introduces several key changes that will promote transparency and consistency in healthcare coverage decisions. … Read More

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CMS Final Rule Analysis 

On April 5, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that requires Medicare Advantage (MA) plans to follow traditional Medicare laws for coverage decisions. It also limits the use of prior authorization, mandates continuity of care for Medicare beneficiaries and establishes a Utilization Management (UM) Committee with a heightened standard for adverse medical necessity decisions. 

The final rule is technically effective as of June 5 2023, although the new utilization management requirements are applicable to coverage beginning Jan. 1, 2024. 

This move is seen as a positive development for healthcare providers, as it brings MA plans closer in alignment with traditional Medicare, which many consider to be the gold standard. 

Ensemble Health Partners’ team of subject matter experts created a quick reference guide with clear and easy-to-understand insights into the MA program changes and their potential impact on you.  

Key Takeaways 

  • MA plans must comply with traditional Medicare coverage criteria requirements and standards. This Final Rule makes regulations clearer in what adherence looks likes, codifies what CMS already thinks and limits when MA plans may create and use their own internal coverage criteria. It adds transparency to coverage determinations for providers and beneficiaries.

  • MA plans can only use the prior authorization process to validate medical necessity and clinical appropriateness of service. MA plans can’t later deny coverage of an item or service based on medical necessity if it previously issued a prior authorization for that item or service. 

  • MA plans must establish a UM committee to review and approve all UM policies and procedures to ensure alignment with traditional Medicare. UM policies and procedures cannot be used for basic or supplemental benefits on or after Jan. 1, 2024, unless those policies and procedures have been reviewed and approved by the UM committee. 

This new rule introduces several key changes that will promote transparency and consistency in healthcare coverage decisions for MA beneficiaries while ensuring healthcare providers are able to provide the best possible care to their patients. Download this quick reference guide to prepare for these changes and hold MA plans accountable to the new requirements. 

View the quick reference e-book here. 

 

These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Neither Ensemble Health Partners, nor any of its employees, are your lawyers. Please consult with your own legal counsel or compliance professional regarding specific legal or compliance questions you have.

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]]> New Revenue Codes to Be Denied by Cigna Without Corresponding CPT or HCPCS Codes https://www.ensemblehp.com/blog/new-revenue-codes-to-be-denied-by-cigna-without-corresponding-cpt-or-hcpcs-codes/ Wed, 03 May 2023 18:06:16 +0000 https://www.ensemblehp.com/?p=10711 Cigna added to the list of codes to be denied if billed without a corresponding CPT or HCPCS code starting May 1, 2023. … Read More

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For Dates of Service beginning May 1, 2023, Cigna added revenue codes 270–279 to the list of codes that will be administratively denied if billed without a corresponding CPT or HCPCS code. These revenue codes are used to bill for generic medical and surgical supplies, such as bandages, dressings and other consumable items, as well as high-cost items like prosthetics, orthotics and implants. Failure to include the appropriate CPT or HCPCS codes on the claim will result in the denial of the line item. Providers may exercise administrative appeal rights in response to these denials.

Who is Affected?

Any provider treating Cigna members may be impacted by this policy expansion. Providers operating under a Percent of Charges (POC) reimbursement model may be most at risk for revenue leakage as a result.

What’s the Impact?

Cigna has estimated anywhere from less than $100 to more than $100,000 annual impact depending on the size of the healthcare organization.

This policy update will likely have minimal impact on high-cost items like pacemaker supplies since those revenue codes are typically always billed with corresponding CPT or HCPCS codes.

However, revenue codes 270–272 for generic supplies typically do not have corresponding CPT or HCPCS codes. While these codes aren’t usually separately reimbursable, they do contribute to the gross allowed charges on a claim. For providers reimbursed through POC payment models, denying these revenue codes and their associate charges means the total charges on the claim will be lower, resulting in lower reimbursement.

While significant revenue impact is unlikely, there are other administrative impacts to consider including skewed denials data, increased pre-bill edits, cost accounting inaccuracy and supply chain management implications.

How To Minimize Risk From Cigna’s Policy Change

Healthcare leaders can take several important steps to minimize the risk of denials and delays caused by Cigna’s recent policy change. These steps include:

  • Review your Charge Description Master (CDM) to ensure it contains up-to-date and accurate hard-coded CPT and HCPCS codes where appropriate.
  • Request revenue and usage reports for the previous year’s Cigna claims that lacked corresponding CPT or HCPCS codes for revenue codes 270-279 to determine the volume of revenue at risk.
  • Keep track of denials related to this policy by checking the claim adjustment segment (CAS) code specified on remittance advice and promptly filing an appeal with the necessary CPT or HCPCS codes.
  • Consider implementing claim edits to prevent claims with revenue codes 270-279 from being submitted without a corresponding procedure code.
  • Review your Cigna contract to determine whether the policy update triggers any material change clause as you monitor real-time results in the coming weeks.
  • Request your annual estimated financial impact from your Cigna representative.

By taking these proactive measures, healthcare providers can avoid unnecessary denials and delays in reimbursement, ensuring smooth revenue cycle management.

In Summary

The recent decision by Cigna to administratively deny claims lacking corresponding CPT/HCPCS codes for revenue codes 270-279 is not expected to have a significant impact on revenue. However, this change does raise some administrative concerns, particularly for providers operating under percent-of-charge payment agreements with Cigna. We will closely monitor the impact of this change as claims processed from May 1 onwards are reviewed and evaluated.

 

These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Neither Ensemble Health Partners, nor any of its employees, are your lawyers. Please consult with your own legal counsel or compliance professional regarding specific legal or compliance questions you have.

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The post New Revenue Codes to Be Denied by Cigna Without Corresponding CPT or HCPCS Codes appeared first on Ensemble Health Partners.

]]> CMS Final Rule: Changes to the Medicare Advantage Program https://www.ensemblehp.com/blog/cms-final-rule-changes-to-the-medicare-advantage-program/ Wed, 03 May 2023 16:05:12 +0000 https://www.ensemblehp.com/?p=10732 Key changes promote transparency in coverage decisions for MA beneficiaries, while ensuring providers can offer the best care for patients. … Read More

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On April 5, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that requires Medicare Advantage (MA) plans to follow traditional Medicare laws for coverage decisions, limits the use of prior authorization, mandates continuity of care for Medicare beneficiaries and establishes a Utilization Management Committee with a heightened standard for adverse medical necessity decisions.

The regulation is set to take effect on June 5, 2023, with the utilization management requirements applicable to coverage beginning January 1, 2024.

This move is seen as a positive development for healthcare providers, as it brings MA plans closer in alignment with traditional Medicare, which many consider to be the gold standard. The American Hospital Association commented the final rule helps curtail “overly restrictive coverage policies that can impede access to care and add cost and burden to the healthcare system.”

Key changes in the final rule include:

  • MA plans must follow traditional Medicare laws when making coverage decisions for basic benefits (Part A and Part B), including national and local coverage determinations (NCD and LCD). This includes criteria for inpatient admissions and the Inpatient-Only List as well as the “two-midnight rule” benchmark for hospital inpatient admissions. When Medicare laws don’t fully establish criteria, MA plans may create their own coverage criteria based on widely used treatment guidelines or clinical literature. These coverage criteria must be publicly accessible, which hopefully will provide much-needed transparency to providers.
  • Prior authorization processes can only be used to confirm medical criteria for coverage determinations for the specific line of service, ensure medical necessity for basic benefits or ensure clinical appropriateness for supplemental benefits. Any prior authorization processes that don’t meet these requirements, including when used for cost containment or delay of services, will be considered non-compliant with CMS regulations.
  • Continuity of care requirements must be met for Medicare beneficiaries with respect to basic benefits. Prior authorization for a course of treatment must be valid for as long as medically necessary to avoid disruptions in care. MA plans must provide a minimum 90-day transition period for beneficiaries who are already undergoing a course of treatment when they enroll in an MA plan. This applies even if the beneficiary’s current provider is out-of-network with the new MA plan.
  • MA plans must establish a Utilization Management Committee to annually review all utilization management policies and procedures, including prior authorization, to ensure they are consistent with Medicare coverage criteria requirements.
  • A heightened standard is applied for physician or other healthcare professionals who review adverse medical necessity decisions. The physician must have “expertise in the field of medicine or healthcare that is appropriate for the services at issue.”

 

In summary, this new rule introduces several key changes that will promote transparency and consistency in healthcare coverage decisions for MA beneficiaries, while ensuring healthcare providers are able to provide the best possible care to their patients.

——–

Cara Tucker has been an attorney for over 10 years, specializing in healthcare and regulatory compliance. She currently serves as legal counsel managing regulatory updates at Ensemble Health Partners, developing legally based strategies and procedures to holistically resolve systemic payor issues to increase revenue, reduce administrative burdens and mitigate risk.

 

These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Neither Ensemble Health Partners, nor any of its employees, are your lawyers. Please consult with your own legal counsel or compliance professional regarding specific legal or compliance questions you have.

RELATED CONTENT

The post CMS Final Rule: Changes to the Medicare Advantage Program appeared first on Ensemble Health Partners.

]]> CMS Proposes Updates to Medicare Advantage Utilization Management Policies + Overpayment Standards: Comments Due Feb. 13 https://www.ensemblehp.com/blog/cms-proposes-updates-to-medicare-advantage-utilization-management-policies-and-overpayment-standards/ Mon, 30 Jan 2023 21:01:47 +0000 https://www.ensemblehp.com/?p=10241 CMS issued a proposed rule that could change utilization management and prior authorization criteria for Medicare Advantage plans. … Read More

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CMS recently issued a proposed rule that, among several other revisions, could change utilization management and prior authorization criteria for Medicare Advantage (MA) plans as well as amend the standard for an identified overpayment – both of which could impact providers. CMS is accepting comments on the proposed rule until Feb. 13, so take this opportunity to make your voice heard.

Potential Changes to MA Authorization Requirements Could Reduce Barriers for Patients + Providers

CMS is looking to address concerns they’ve heard loud and clear in recent years – the utilization management process, including prior authorizations, for MA plans can create unnecessary barriers to patients’ access to medically necessary care. CMS cited a 2022 report by the Office of the Inspector General (OIG) which found some MA plans inappropriately deny prior authorization requests even when the services meet Medicare coverage guidelines.

To address these concerns, CMS proposes MA plans follow the same coverage criteria and utilization management policies as Traditional Medicare to significantly reduce the administrative burden on providers and ensure Medicare enrollees have consistent access to medically necessary care without unreasonable barriers or interruptions.

Specific proposed changes include:

  • MA coordinated care plans (HMO, PPO) may only use prior authorization policies to:
    • Confirm the presence of diagnoses or other medical criteria that are the basis for coverage determinations for the specific item or service
    • Ensure a basic benefits item or service is medically necessary based on specific standards, or
    • Ensure a supplemental service or benefit is clinically appropriate.

  • MA plans must ensure that any approvals it grants through prior authorization processes will be valid for the duration of the approved course of treatment and that it provides a minimum 90-day transition period when an enrollee who is currently undergoing treatment switches to a new MA plan.

  • MA plans must comply with national coverage determinations (NCD), local coverage determinations (LCD) and general coverage and benefit conditions included in Traditional Medicare statutes and regulations as interpreted by CMS. This proposal is designed to prohibit MA plans from limiting or denying coverage when the item or service would be covered under Traditional Medicare. The proposed revisions indicate that the Traditional Medicare coverage criteria for inpatient admissions, Skilled Nursing Facility (SNF) care, Home Health Services, and Inpatient Rehabilitation Facilities (IRF) would apply to basic benefits in the MA program.

  • MA plans cannot deny coverage of a Medicare covered item or service based on internal, proprietary, or external clinical criteria not found in Traditional Medicare coverage policies. When there are no applicable coverage criteria in Medicare statute, regulation, NCD, or LCD, MA organizations may create internal coverage criteria that are based on current evidence in widely used treatment guidelines or clinical literature that is made publicly available to CMS, enrollees and providers.

  • MA plans must establish a Utilization Management Committee to review all utilization management policies annually, including prior authorization and ensure they are consistent with current traditional Medicare’s national and local coverage decisions and guidelines.

Submit a comment at Regulations.gov voicing your support for these changes before Feb. 13. Here is the comment we are submitting as an example.

Changing the Standard for an “Identified Overpayment”

CMS’s proposed rule also seeks to amend the standard for an identified overpayment from its current “reasonable diligence” standard to the False Claims Act’s “knowing” standard. Under the proposed rule, an MA organization, Part D sponsor, provider, or supplier has identified an overpayment if it has actual knowledge of the existence of the overpayment or acts in reckless disregard or deliberate ignorance of the overpayment.

The current “reasonable diligence” standard was challenged in recent litigation involving UnitedHealthcare. These proposed changes to the overpayment standard appear to be in response to the court decisions associated with that litigation. The proposed removal of the “reasonable diligence” standard and adoption of the FCA “knowledge” standard for overpayments would apply to Medicare Parts A, B, and D, in addition to Part C.

Providers should continue to monitor these proposed changes to anticipate any needed changes to their compliance programs.

 

 

 


Contact one of our revenue cycle experts today if your organization needs support or has further questions.

These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Neither Ensemble Health Partners, nor any of its employees, are your lawyers. Please consult with your own legal counsel or compliance professional regarding specific legal or compliance questions you have.

RELATED CONTENT

The post CMS Proposes Updates to Medicare Advantage Utilization Management Policies + Overpayment Standards: Comments Due Feb. 13 appeared first on Ensemble Health Partners.

]]> Be Prepared for Increased Medicare Bad Debt Compliance Scrutiny https://www.ensemblehp.com/blog/be-prepared-for-increased-medicare-bad-debt-compliance-scrutiny/ Sat, 28 Jan 2023 16:03:31 +0000 https://www.ensemblehp.com/?p=10185 OIG and CMS agree more scrutiny is needed for Medicare bad debt reimbursement and encourage more regular review of bad debts claimed. … Read More

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Between 2016 and 2018, healthcare providers sought $10 billion in reimbursement for Medicare bad debt, prompting an audit by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) to examine providers’ compliance with Federal bad debt reimbursement requirements.

To perform its audit, OIG randomly selected 67 provider cost reports from which it pulled a sample of 148 bad debts. Of that sample, OIG identified 18 instances where providers didn’t comply with Federal requirements regarding reasonable collection efforts before claiming reimbursement. OIG further identified four discrepancies between the amounts claimed for reimbursement versus the amounts owed by Medicare beneficiaries. In total, these instances of noncompliance resulted in roughly $30,000 of unallowable Medicare reimbursement.

During its audit, OIG observed 29 instances in which providers complied with Federal requirements but didn’t follow their own internal policies and procedures when collecting Medicare coinsurance and deductibles from beneficiaries. OIG noted that, “[p]roviders that do not comply with their own stated policies and procedures are at an increased risk that they will not comply with Federal requirements.”

OIG + CMS Agree More Scrutiny is Needed for Medicare Bad Debt Reimbursement

OIG recommended to the Centers for Medicare & Medicaid Services (CMS) that it consider issuing instructions or guidance to the Medicare Administrative Contractors (MACs) that would require or encourage the MACs to more regularly review Medicare bad debts claimed on cost reports. OIG suggested that CMS define individual Medicare bad debt thresholds to trigger audits.

In a written letter from Administrator Chiquita Brooks-LaSure, CMS agreed with OIG’s recommendations and stated that it would consider OIG’s findings when issuing future guidance to the MACs regarding the review of Medicare bad debts. CMS also stated that MACs do perform regular reviews of Medicare bad debts and recouped $294 million from providers during the fiscal years 2016 through 2018.

Take Action to Reduce Medicare Bad Debt Compliance Risk

Medicare bad debt compliance continues to draw federal regulatory scrutiny, and this recent report from OIG indicates it may only increase in the future. This OIG report highlighted the need for regular associate education and corresponding internal auditing program. By creating a comprehensive collections policy and auditing program, you help ensure that your organization is prepared for an OIG audit and reduce the risk of FCA actions, which may result in costly damages and penalties. For tips to mitigate risk and enhance regulatory compliance, review our article on Medicare bad debt.


Contact one of our revenue cycle experts today if your organization needs support or has further questions.

These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Neither Ensemble Health Partners, nor any of its employees, are your lawyers. Please consult with your own legal counsel or compliance professional regarding specific legal or compliance questions you have.

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