At Healthcare Information Services (HIS), we stay on top of the latest updates within the healthcare industry, so that you don’t have to go far for the information your practice needs. One very common source of updates is the Centers for Medicare & Medicaid Services (CMS). Since July 1st of this year, CMS and private insurers have made several updates that spine surgeons should be aware of. With the help of Becker’s ASC Review, we’ve broken down these updates below – keep reading to get the information you need.
1. Pre-authorization for Therapy Programs
Starting on September 1st, UnitedHealthcare began to require prior authorization for a variety of therapy services delivered in both multidisciplinary offices and outpatient hospital settings. These include physical therapy, occupational therapy, speech therapy, and Medicare-covered chiropractic services.
2. Gold-Card Program for Eligible Providers
October 1st, 2024 will mark the beginning of a new national gold-card program from UnitedHealthcare. In order to be eligible, providers must constantly adhere to evidence-based guidelines to bypass prior authorizations for certain medical services. Practices need to be in-network for at least one line of business for the past two consecutive years. They also need to have a minimal annual volume of at least 10 prior authorizations and have a prior authorization approval rate of 92% or more after appeals, on the eligible prior authorization volume. The program applies to several plans, including commercial, individual exchange, Medicare Advantage, and community plans.
3. Price Negotiations for Medications
This past August, the U.S. government announced negotiated prices for 10 medications under President Biden’s Inflation Reduction Act. These medications include:
- Eliquis
- Jardiance
- Xarelto
- Januvia
- Farxiga
- Entresto
- Enbrel
- Imbruvica
- Stelara
- Diabetes medications including Fiasp, Fiasp FlexTouch, Fiasp PenFill, NovoLog, NovoLog FlexPen, and NovoLog PenFill
Following this update, analysts began to predict that Novo Nordisk’s Ozempic may see price negotiations in 2027.
4. Transforming Episode Accountability Model
This new five-year, episode-based payment model was proposed by CMS in April and is expected to come into play soon. The Transforming Episode Accountability Model will affect orthopedics and spine, and requires select acute care hospitals to coordinate care for patients undergoing surgical procedures during and after their hospital stay. Hospitals must assume responsibility for the cost and quality of care for the first 30 days after a traditional Medicare patient leaves the hospital. This proposal includes lower joint replacements, spinal fusions, and surgical hip femur fracture treatment.
5. Removal of MRI Lumbar Spine for Lower Back Pain
The recently proposed 2025 ASC and hospital outpatient prospective payment rule from CMS includes the removal of lumbar spine MRI for low back pain. This change was made based on studies suggesting that “performance or improvement on the measure did not result in better patient outcomes.”
6. Proposed Changes to the 2025 Physician Fee Schedule
Proposed changes to the 2025 physician fee schedule were also revealed on July 10th, with several spine surgeons expressing concern about this update. The proposal includes a potential 2.8% conversion factor decrease from 2024.
Support for Orthopedic and Radiology Practices from HIS
Whether you are an orthopedic practice trying to navigate new CMS changes or a radiology group wanting to improve your revenue cycle, our experts at HIS are here for you. We help orthopedic and radiology practices across the country tackle challenges, optimize productivity, and increase profitability. With expertise in practice management, revenue cycle management, medical coding, and more, you’ll find the partner you’ve been looking for with HIS. To speak to a member of our team about how we can help you, please contact us today!