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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.

Cincinnati, Ohio, – Sept. 21, 2023 – Ensemble Health Partners (“Ensemble”), the leading revenue cycle management company for hospitals, health systems and physician practices, received the top score for overall performance among end-to-end revenue cycle outsourcing vendors in KLAS Research’s End-to-End Revenue Cycle Outsourcing (“RCO”) 2023 Performance Report.

The stated goal of this bill is to prevent HOPD rates from being paid for services rendered in free-standing physician offices or other settings that should be reimbursed at a lower cost. There is also speculation the bill might be the first step in a larger reimbursement model overhaul aimed at aligning HOPD reimbursement rates with those of ASCs and physician practices.

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 (UM) Committee with a heightened standard for adverse medical necessity decisions.