Becker's ASC Review

8 ASC MANAGEMENT UnitedHealthcare to cut prior authorization usage by 20% By Claire Wallace U nitedHealthcare plans to cut back on its use of prior authorization, removing procedures and medical devices from its list of services requiring signoff and reducing the number of authorizations from 13 million to 10 million annually, according to a March 29 report from e Wall Street Journal. Several procedures and devices will be removed starting in the third quarter. e insurer also plans to automate and speed up prior authorization over the next several years, according to the report. In 2024, the insurer will also eliminate several prior authorization requirements for its "gold-card" physicians and hospitals, or those who nearly always get their requests approved. Other insurers, including the Cigna Group and CVS' Aetna, are removing prior authorization requirements and automating the process as well. While insurers claim that prior authorization tamps down costs and helps patients get the best care, physicians argue that the process is time-consuming and ineffective. According to a March study from the American Medical Association, prior authorization has delayed patient care for 94 percent of physicians. "We all know that requiring prior authorizations really only leads to more bureaucracy within the insurance company, as well as within each healthcare provider's practice, because now we need people to fill out these prior authorization forms, waste time trying to get through their 1-800 number to speak with someone who has no clinical knowledge, then be told we need to speak with someone else who actually does have some medical knowledge about why these procedures are necessary. is thereby leads to increased costs because we all need to hire more people to handle these needless requests," Linda Lee, MD, medical director of endoscopy at Boston- based Brigham and Women's Hospital and associate professor of medicine at Harvard Medical School, told Becker's. "We're not deaf to the complaints out there," Philip Kaufman, chief growth officer at UnitedHealthcare, told e Wall Street Journal. "We've taken a hard look at ourselves and this process." In 2022, the Department of Health and Human Services reported that 13 percent of prior-authorization denials by Medicare Advantage plans were for benefits that should have been covered, according to the report. United has yet to specify what services will be affected by the change but suggested they will include certain types of medical equipment and genetic testing used for diagnosis. n Is CMS pushing procedures away from ASCs? 5 moves to know By Patsy Newitt F rom its reversal on the inpatient only list to removing procedures from the ASC-approved list, CMS seemingly has been erratic with its ASC policies. Here are the biggest regulatory shifts that have shaped the ASC industry in the last six years, according to VMG Health's 2023 mergers and acquisitions report released March 21: 1. In 2018, CMS removed total joints from the inpatient- only list, pushing payers to become more willing to cover total joints in the outpatient setting. CMS also added 12 cardiac catheterization procedures to the ASC-approved list. 2. In 2020, CMS approved total knee arthroplasty for Medicare payment at ASCs, along with knee mosaicplasty, six coronary intervention procedures and 12 procedures with new CPT codes. 3. In 2021, CMS announced its plan to phase out the inpatient-only list. In 2022, however, CMS said it would reverse its course on this change that had added a number of codes to the ASC-approved list. This move pushed many procedures back to the inpatient- only list, slowing the migration of procedures to the outpatient setting, according to the report. 4. For its 2023 final rule, CMS considered 64 recommendations for new procedures to be added to the ASC-covered procedures list, but only four procedures that are typically performed in an outpatient setting were chosen. 5. With its 2023 final rule, CMS implemented a policy that will provide complexity adjustments for certain ASC procedures. According to the report, these adjustments will be applied to "combinations of primary procedures and add-on codes deemed eligible under the hospital [outpatient prospective payment system]." Formerly, add-on codes did not receive more reimbursement when bundled with primary codes. With this new policy, Medicare will provide adjustments to the payment rate to account for the costs of specific services. n

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