On April 12, the Centers for Medicare & Medicaid Services (CMS) published a final rule that establishes long-sought standards that Medicare Advantage (MA) plans must follow when they use prior authorization and other utilization review techniques to administer healthcare claims, including claims for O&P care. Given the fact that the MA program covers more than half of all patients with Medicare coverage, this is a major advance for providers and patients, whose care is often inappropriately delayed or denied through prior authorization and similar MA tactics, all designed to boost profitability of these plans.
The final rule is effective on June 5, but the rule states that the new regulations will be included in MA plan documents starting January 1, 2024. O&P practitioners are strongly advised to review these new MA rules, commit them to memory, and use knowledge of them in negotiations with MA plans on behalf of patients who are denied approval for prior authorization of O&P care. This article summarizes key policies in the final rule including the following:
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