Tag: Tech

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TECH- New Mexico Awards Contract for New Medicaid Management

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Conduent just won another “modular” procurement, with claims and financial as the foundation. Some HCBS and Rx stuff got tacked on, too.

 
 

 
 

Clipped from: https://www.globenewswire.com/news-release/2023/02/14/2607661/0/en/New-Mexico-Awards-Contract-for-New-Medicaid-Management-Information-System-to-Conduent.html

 
 

New Mexico Human Services Department’s current Medicaid Management Information System to be replaced with Conduent’s modular cloud-based technology platform

Conduent’s solution will streamline enterprise Medicaid claims and will provide financial, pharmacy benefit management and data exchange and reporting services

FLORHAM PARK, N.J., Feb. 14, 2023 (GLOBE NEWSWIRE) — Conduent Incorporated (Nasdaq: CNDT), a global technology-led business process solutions company, today announced that it has been selected by the New Mexico Human Services Department (NMHSD) to deliver a new Medicaid Management Information System (MMIS) to replace the agency’s existing system. Conduent’s Medicaid Suite (CMdS), a modular, cloud-based technology platform, will create a seamless experience for providers and improve access for approximately one million state Medicaid members.

Conduent will manage the system implementation, and provide maintenance and enhancements designed to reduce costs while optimizing the state’s Medicaid operations. The CMdS Financial and Claims Modules will form the foundation to transform NMHSD’s MMIS into a future-ready system to support well-coordinated services for providers and members. The all-encompassing replacement project includes the following services:

  • Enterprise Claims Processing (including medical claims, pharmacy claims, non-medical claims, and other payment types)
  • Self-Directed Home and Community Based Services
  • Pharmacy Benefit Management Services
  • Drug Rebate Management Services 
  • Data Exchange and Reporting Services
     

“Conduent brings the expertise and solutions that will help position the Human Services Department for the future. By automating manual processes and promoting interoperability between IT systems, operations will become more efficient and effective. We anticipate that the project will also bring significant improvements to help our Medicaid providers by creating a single point of entry for all claims and a streamlined billing process. These and other updates will make it easier for NMHSD and its sister agencies to capture data necessary for measuring and improving health outcomes for our customers,” said Kari Armijo, Acting Secretary, New Mexico Human Services Department.

Conduent provides government agencies with a range of solutions for healthcare, payments and eligibility services, as well as child support and constituent engagement. The company supports approximately 41 million residents annually with various government health programs and processes more than 155 million Medicaid claims every year for 23 states.

“Conduent has proudly served the state of New Mexico for the last 29 years. We are pleased to continue our successful collaboration, now focusing on the transformation of the state’s MMIS technology infrastructure. Our commitment is to bring best-in-class solutions and services that help the Human Services Department meet the mandates to reduce program costs and improve the lives of all New Mexicans,” said Mark King, President of Conduent Government Solutions.

In addition to CMdS and Pharmacy Benefit Management solutions, Conduent’s offerings for the government health sector include its Maven® Disease Surveillance and Outbreak Management Platform and the BenePath® Suite to modernize the eligibility and enrollment process for social services and government aid programs.

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TECH- CMS Improves Medicaid Reimbursement for Digital Health Consults

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Now specialists can bill for telehealth so we can stop gaming what the PCPs are getting paid to cover the specialists costs.

 
 

Clipped from: https://www.healthleadersmedia.com/technology/cms-improves-medicaid-reimbursement-digital-health-consults

The Centers for Medicare & Medicaid Services has issued guidance changing Medicaid and CHIP coverage for eConsults, or provider-to-provider specialty consults conducted via digital health or telehealth. The  ruling could expand the service, which helps primary care providers keep more of their patients and boosts access to care for underserved patients.

KEY TAKEAWAYS

The Centers for Medicare & Medicaid Services has issued new guidance on Medicaid and CHIP coverage for eConsults, or interprofessional consultations between a primary care provider and a specialist on treatment for a specific patient.

Under the new guidance, specialists are able to bill Medicaid for eConsults rather than primary care providers, who would often have to bill higher rates so that they could reimburse specialists for their services.

The platform is popular with primary care providers who want to keep more of their patients and specialists who want to expand their reach, while it improves access to care for underserved populations who can’t afford or won;t travel to see a specialist.

Federal officials have expanded coverage for specialty consults between care providers via digital health for Medicaid and Children’s Health Insurance Program (CHIP) members.

In guidance issued earlier this month, the Centers for Medicare & Medicaid Services (CMS) announced that interprofessional consultations, or instances when a care provider seeks the advice of a specialist for a patient’s treatment, via eConsults can be covered by state Medicaid or CHIP programs even when the patient is not present, as long as the consult is focused on that patient.

eConsults are clinical consults usually conducted via telemedicine (including the telephone) or digital health. They enable primary care providers to expand care management options for their own patients without having to send those patients off to a specialist. And they improve access to care for patients who might not want to travel to see a specialist due to a variety of reasons, including distance and cost.

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Alongside helping primary care providers retain more of their patients, the platform is popular with federally qualified health centers (FQHCs) and community health centers who treat underserved populations and in rural areas where access to specialists is scarce. It also helps specialists expand their reach and treat more patients in need of their services.

“Timely access to specialty providers can improve the quality of care and treatment outcomes for both physical and behavioral health,” CMS wrote in its guidance. “While access to specialty care has been a challenge across a range of specialties, access to specialty care for mental health and substance use disorders has been a particular challenge.”

The ruling changes the payment model so that the consulting provider, or the specialist, can bill for the treatment. Previously, CMS allowed the treating provider to bill Medicaid, which in many case forced the program to pay higher rates to the treating provider so that he/she could reimburse the specialist for consulting services.

To qualify eConsult coverage, both care providers must be enrolled in the Medicaid program in the state where the patient is located, though the consultant can be located in another state.

“Given the potential for improving access to specialty care, a number of states have obtained authority through state legislation for or expressed interest in covering eConsults,” the Los Angeles-based Manatt, Phelps & Phelps law firm wrote in a recent blog. “States that choose to cover eConsult codes must submit a state plan amendment to CMS to add a payment methodology for the qualifying service, and should consider broadly communicating any related policy changes to their enrolled provider community.”

 
 

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Town Hall Ventures’ Andy Slavitt on how to invest in Medicaid

 
 

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Andy’s got some ideas on how to make money in Medicaid.

 
 

Clipped from: https://www.statnews.com/2023/01/31/town-hall-ventures-medicaid-slavitt-health-tech/

 
 

SAN FRANCISCO — Part of Andy Slavitt’s core mission at Town Hall Ventures is proving that health tech companies can make a viable business out of reaching low-income people who also face social challenges, like a lack of housing or nutritious food options. It’s a bold assertion that hasn’t been proven out yet, though a handful of Town Hall Ventures’ portfolio companies — including Unite Us and Alphabet spinout Cityblock  — have already achieved valuations over $1 billion.

The stakes are growing steadily higher, especially for the millions who signed up for Medicaid coverage during the public health emergency and who risk losing it as temporary expansions end. And by investing in teams they trust to embed in vulnerable communities, build culturally sensitive products, and develop sophisticated analytics to assess social needs, Slavitt and his team are hoping to set an example for other venture funds who have historically avoided Medicaid.

“The clinical answers are not so hard. I can’t emphasize that enough,” Slavitt said. Though the diagnoses affecting low-income patients are largely the same as the ones affecting those with commercial insurance, the health care system isn’t set up to accommodate homeless people, or medically complex pediatric patients in health care deserts, he said. 

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“What’s different largely speaking is that being poor really sucks and being miles away from anyone who can really care for you really sucks and needing to fill out 10 forms to get housing or child care or any of these other things is a big deterrent to getting care,” he said. “A system that doesn’t welcome you, doesn’t recognize where you live, really doesn’t work.” 

From an investment perspective, he said, there’s potential for a “decent margin — not a huge margin” in helping the country’s roughly 90 million Medicaid patients get better preventive health care, avoiding more expensive treatment in the future. “There’s no bigger market than Medicaid,” he said. 

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STAT spoke with Slavitt in San Francisco, where he and other investors and health care executives descended earlier this month for the J.P. Morgan Health Care Conference. This conversation has been edited for length and clarity. 

What types of companies do you think are best equipped to solve these problems?

The good news is there’s an awakening that the most needed area of investment is also investable space. Not everyone has figured it out.

There’s two types of ways of thinking about investing. One starts with how do I find a market opportunity and make a lot of money? And the other starts with is there a really big problem that I can figure out how to solve? Not every problem in health care will be solved with innovation. But some can, and the ones that can are the ones where you’ve got a clinical, social, behavioral model that addresses the need of a specific population where there’s also some payment model that allows you to meet those needs.

If you look across Medicaid, you can follow the journey from moms to babies, pregnant moms to pediatrics, complex pediatrics, then school-based programs, justice and teen mental health programs, disability, all the way up to [dual Medicare and Medicaid eligibles and eldercare]. We have activities in all those buckets. We have investments in most of those buckets. 

Finding people who really understand these problems at a really operational finite level [is important]. Take a company like Cityblock Health. There are several thousand available housing units in New York that don’t get used for homeless people because they’re only available for people with a psych diagnosis. And in order to get a psych diagnosis, you’ve got to go find a psychiatrist in New York, then make it to the appointment, then it gets rejected. … They’ve got a team of psychiatrists that do that, nothing but that, and they get people into housing. 

How will you know you’ve been successful?

If we’re massively successful, [Town Hall] will invest a few billion dollars over our life into these communities. We need hundreds of billions of dollars invested, and there’s all this capital that sits there trapped [in the health care industry] … or is repatriated to shareholders because these are incredibly profitable companies. And they come into these communities and they take the profits out. Money needs to be reinvested back into these communities. 

Do the communities you’re focused on use technology any differently than wealthier ones?

SMS is less expensive to use than a browser. There are subtleties. I went out to the field with a Cityblock community health partner and I said, “What’s your favorite part of your job?” And she said, “My iPad.” I don’t hear that a lot in health care, but she said, “I bring this into someone’s apartment and I can build access to the whole world for them. I can connect them to the thing they need, I can order something for them on the spot and they can see action. I can communicate with their daughter who is a big user of technology.” 

Amazon has a lot to teach us in coming into health care because they know how to deploy technology in ways that don’t feel like technology. 

How are the metrics you use to evaluate companies different from other markets?

It’s imperfect and it’s a little bit of a moving target. We started in earnest on it probably a year ago. We got more resources on our team to be able to collect the information from our companies. It was always part of the process but if you’d asked me the question for each one how are they doing, I wouldn’t have been able to give you a great answer. 

One easy tell, when I talk to a company, is, “Tell me what it is.” Plume, which is a trans health company, they’re like, “we have to reduce anxiety and depression scores very fast.” So they measure that like crazy. If I look at Eleanor Health, which is focused on addiction and recovery treatment, what they basically want to get to is lower craving levels. They don’t measure urine tests [as much] … they’ve learned that the frequency of touch points with people at various stages of their addiction recovery is really important, so they’ll measure that.

There’s a set of consistent metrics, but you’ve got to respect them to tell their own story. At some level they’re going to know their business better. 

If I don’t hear that they’re measuring Net Promoter Score rabidly in the right way, it tells me, OK there’s some other way you’re getting paid than doing your job. 

There’s questions we ask every company like diversity on your management team, diversity on your board, diversity at each level, diversity of promotions. There’s usually other investors at the table, and I’m pretty sure they’re going to ask the question about “how’s your sales acquisition doing?” But my first questions will always be what I think is important. You have to hire diversity, particularly in the early stages, and then their networks will come in. But you have to force it. 

This story, part of a series on health tech for underserved populations, was supported by USC Annenberg Center for Health Journalism’s national fellowship.

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TECH- Insurers, states can now text Medicaid beneficiaries

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: The federalis are loosening anti-spam text laws to help states/MCOs deal with the Return to Normal Operations.

 
 

 
 

Clipped from: https://www.fiercehealthcare.com/payers/managed-care-plans-states-can-now-text-medicaid-beneficiaries-warn-enrollment-changes

 
 

 

From <https://chat.openai.com/chat>

 
 

 
 

 
 

 
 

Managed care plans and states can now deliver robocalls and texts Medicaid beneficiaries without fear of violating a federal law, a critical change as states face eligibility redeterminations in a few months. 

The Federal Communications Commission (FCC) released new guidance Tuesday on the change after getting a letter from the Department of Health and Human Services (HHS) back in April 2022. States and managed care plans face a looming April 1 deadline to start redetermining the eligibility of everyone on Medicaid.

FCC’s goal is to ensure that “millions of Americans can receive the information they need to maintain enrollment in Medicaid and other governmental healthcare programs to avoid losing healthcare coverage,” according to an agency release. 

The guidance said that states and partners that include local agencies and managed care plans can under certain circumstances use robocalls or automated texts to raise awareness of eligibility issues.

HHS wrote a letter to FCC in April 2022 asking for an exception to the federal anti-robocall law, noting that states and managed care plans have looked to automated robocalls and texts to remind beneficiaries to respond to requests from their local Medicaid agency. 

FCC’s guidance comes at a pivotal time for states and managed care plans. At the onset of the pandemic, the federal government agreed to boost the matching rate for Medicaid payments, but only if the state did not drop anyone off Medicaid’s rolls for the duration of the COVID-19 public health emergency.

The PHE remains in effect until later this year, but Congress included a provision in a spending bill late last year that allowed states to start eligibility redeterminations April 1. The provision also phased out the bump to the matching rate for the rest of the year.

States and managed care plans have been prepping for months for the redeterminations to start, and a key issue has been outreach to affected beneficiaries. 

It remains unclear whether future exceptions will be granted to the Telephone Consumer Protection Law, a 1991 statute that restricted the use of robocalls. 

Insurers have been pressing the FCC to expand a 2015 order that enabled healthcare auto-calls. 

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TECH- Chances of State Medicaid Programs Bringing Telehealth Services Into ‘23 are High

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Telehealth for BH remains the most likely contender for survival of any post-pandemic clawback.

 
 

Clipped from: https://www.managedhealthcareexecutive.com/view/chances-of-state-medicaid-programs-bringing-telehealth-services-into-23-are-high

Medicaid officials of 44 states (including the District of Columbia) responded to a KFF survey about policies and trends relating to telehealth delivery of behavioral health services. Officials reported high utilization rates of telehealth services for behavioral health purposes since the beginning of the pandemic and plan to continue telehealth expansion permanently.

Telehealth seems to be a necessity when accessing behavioral health services for Medicaid users.

In 2022, behavioral health, especially mental health, remained a top service category with high telehealth utilization among Medicaid enrollees.

In a recent KFF survey, state Medicaid officials were asked about their telehealth delivery policies and trends when it came to behavioral health. Out of all U.S. states only 44 (including the District of Columbia) participated. Responses resulted in many seeking permanent adoption of pandemic-era telehealth policy expansions.

Early in the pandemic, all 50 states expanded coverage and/or access to telehealth services in Medicaid. Respondents of the survey stated they took at least one specified Medicaid policy action to expand access to behavioral healthcare through telehealth. For example, states expanded behavioral health provider types eligible to provide Medicaid services through telehealth. States also expanded categories of Medicaid behavioral health services eligible for telehealth delivery. Lastly, states newly allowed or expanded their audio-only services.

As of July 1, 2022, states were more likely to offer this audio-only services.

Audio-only coverage was reported to help facilitate access to care, especially in rural areas with broadband access challenges and for older populations who may struggle to use audiovisual technology.

While, many states reported high utilization of telehealth for behavioral healthcare after, some noted utilization trends among certain subgroups of Medicaid enrollees.

These trend subgroups include:

  • Geographic: With states most commonly reporting particularly high behavioral health telehealth utilization in rural areas compared to urban areas.
  • Demographic: These trends indicate behavioral health conditions are most prevalent among young adults and White people. In particular, some states reported younger enrollees (including children and non-elderly adults) were most likely to utilize telehealth for behavioral health care.
  • Temporal: States have frequently reported behavioral health telehealth use has declined from its peak earlier in the pandemic, but remains high compared to the pre-pandemic period. Future policy changes, such as to further expand or to limit telehealth flexibilities, may impact ongoing utilization.

Nearly all responding states found some of these trends by monitoring utilization in 2022. Many plan to begin doing so in 2023, which is important for the future of Medicaid telehealth policy for behavioral health as it relies on continued analysis of utilization and other data, as well as federal guidance.

As states continue and expand their monitoring, the results of these analyses may provide information that can inform policy decisions.

For example, the Bipartisan Safer Communities Act signed into law in June 2022 directs CMS to issue guidance to states on options and best practices for expanding access to telehealth in Medicaid, including strategies for evaluating the impact of telehealth on quality and outcomes, KFF said. CMS must then issue this guidance by the end of 2023.

The Consolidated Appropriations Act passed in December 2022 authorized additional telehealth provisions, such as requirements for Medicaid provider directories to include information on telehealth coverage and for CMS to issue guidance on how states can use telehealth to deliver crisis response services.

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Tech- Wyoming Receives CMS Certification for Its Medicaid Provider Management System Delivered by HHS Technology Group

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Yeah it’s a self-serving press release, but it is interesting to see progress on the decades long path to modularity.

 
 

Clipped from: https://finance.yahoo.com/news/wyoming-receives-cms-certification-medicaid-121100422.html?guccounter=1&guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAALMMY3tMR3RhrBoLTCC4IVoMnJqTkqJLK9JvU3K6_47OwWsDqX-MvLdIM-nGFWO39Gv-jR5JqFS5UF0j6GZh55r-5lDL3rrJUfch3b7NXpM7nSCrrZePaXTlrzUbV_EF3nWn5iftRoHCVIcvk4mdCEoLkf12knLVhqBSHzgeCuGg

Discover your Provider® solution streamlines enrollment, screening, and monitoring for Wyoming’s Medicaid providers

FORT LAUDERDALE, Fla., Jan. 3, 2023 /PRNewswire/ — HHS Technology Group, LLC™ (HTG) announced today the Wyoming Department of Health (WDH) received final certification from the Centers for Medicare & Medicaid Services (CMS) for its Provider Enrollment, Screening, and Monitoring (PRESM) system powered by HTG’s Discover your Provider® (DyP®) solution. DyP® offers an advanced online provider portal with electronic and self-service capabilities, such as provider enrollment and license verification, with proven success in improved operational efficiencies, added convenience, and simplified processes, resulting in increased cost savings and a better provider experience.

 
 

HHS Technology Group is a software and solutions company serving the needs of commercial enterprises and government agencies. HHS Tech Group delivers purpose-built, modular software products, solutions, custom development, and integration services for modernization and operation of systems that support a wide spectrum of business and government needs. For more information about HHS Technology Group, visit www.hhstechgroup.com. (PRNewsfoto/HHS Technology Group)

“We are pleased to collaborate with HHS Technology Group to launch the PRESM system,” said Jesse Springer, Medicaid Technology and Business Operations Section Manager, Wyoming Department of Health. “We believe we now have one of the fastest, if not the fastest, Medicaid provider enrollment and re-enrollment systems and processes in the nation.”

A cloud-based, holistic platform, DyP® serves as the system of record for all of Wyoming’s Medicaid, Kid Care CHIP, and WDH provider enrollments. HTG’s contract with Wyoming’s Division of Healthcare Financing includes the operation, maintenance, and enhancement of the PRESM system, which has been in production since April 2021. HTG’s call center also provides critical support and technical assistance to Wyoming Medicaid providers.

“For states to properly administer Medicaid programs that efficiently deliver high-quality medical services to vulnerable populations, it is critical to have clean, accurate, reliable provider data,” said Bradley White, CEO of HTG. “With the launch of PRESM, Wyoming now has an industry-leading solution to optimize all provider management processes, including screening, enrollment, and monitoring.”

In addition to facilitating and promoting greater provider participation, DyP® leverages a modular design for increased functionality and leading-edge technology to streamline once-seemingly cumbersome and time-consuming processes significantly. The significant value delivered by DyP® to states and providers includes:

  • Reduced enrollment time for new providers from over one month to under five days.
  • Significantly reduced state and contractor burden and time (approximately 2 FTEs) from the previous manual process for new applications, renewals, and licensing updates.
  • A fully integrated pharmacy provider enrollment process with streamlined monitoring.
  • A 100% electronic provider agreement process, including signatures.

Notably, DyP® is one of six certified Medicaid Management Information System (MMIS) provider solutions, and HTG is among the few companies to obtain certification for multiple modules, as evaluated and awarded by the National Association of State Procurement Officials NASPO) ValuePoint contracting arm. Most recently, HTG’s Recover your Liability® (RyL®) solution, which automates third-party liability functions and integrates with other MMIS modules, earned NASPO ValuePoint certification.

To learn more about HTG’s Discover your Provider® platform and its proven success, visit HHS Technology Group online.

About HHS Technology Group, LLC

HHS Technology Group (HTG) is a software and solutions company serving the needs of commercial enterprises and government agencies. HTG delivers modular software solutions, custom development, and integration services for the modernization and operation of systems supporting a broad spectrum of business and government needs. For more information about HHS Technology Group, visit www.hhstechgroup.com.

Media Contact: 
Janet Mordecai
Amendola Communications (for HHS Technology Group)
jmordecai@acmarketingpr.com

 
 


Cision

View original content to download multimedia:https://www.prnewswire.com/news-releases/wyoming-receives-cms-certification-for-its-medicaid-provider-management-system-delivered-by-hhs-technology-group-301712112.html

SOURCE HHS Technology Group

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TECH- Inconsistent Medicaid coverage for remote patient monitoring hampers adoption

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: RPM is taking off in some areas, but needs more money.

 
 

Clipped from: https://www.insiderintelligence.com/content/scattershot-medicaid-coverage-remote-patient-monitoring-hampers-adoption

The trend: Remote patient monitoring (RPM) interventions can help low-income individuals get healthier. But more consistent state Medicaid coverage will be necessary for these programs to scale up.

What’s driving the trend? Providers and patients are more bullish on using technology to manage their conditions. So, health systems are using more RPM programs and investors are pouring money into RPM-focused tech startups.

Reimbursement roadblocks: Providers have struggled to capture complete reimbursement from insurers for their RPM programs. Many organizations rely on grants or donations to jumpstart an intervention.

The Centers for Medicare & Medicaid Services recently increased the types of remote monitoring services it will cover for Medicare patients, but Medicaid is a different story.

The opportunity: States are proceeding with caution when it comes to covering RPM services, mostly because they want to see more evidence proving that remotely monitoring patients will be cost efficient for Medicaid and clinically valuable for patients.

Health systems have an opportunity to validate the effectiveness of their RPM interventions, particularly for vulnerable populations.
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TECH- CMS Proposes Rule to Expand Access to Health Information and Improve the Prior Authorization Process

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: CMS wants everybody (ok most) to do lots of new stuff around prior auths.

 
 

Clipped from: https://www.cms.gov/newsroom/press-releases/cms-proposes-rule-expand-access-health-information-and-improve-prior-authorization-process

As part of the Biden-Harris Administration’s ongoing commitment to increasing health data exchange and investing in interoperability, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would improve patient and provider access to health information and streamline processes related to prior authorization for medical items and services. CMS proposes to modernize the health care system by requiring certain payers to implement an electronic prior authorization process, shorten the time frames for certain payers to respond to prior authorization requests, and establish policies to make the prior authorization process more efficient and transparent. The rule also proposes to require certain payers to implement standards that would enable data exchange from one payer to another payer when a patient changes payers or has concurrent coverage, which is expected to help ensure that complete patient records would be available throughout patient transitions between payers.

“CMS is committed to strengthening access to quality care and making it easier for clinicians to provide that care,” said CMS Administrator Chiquita Brooks-LaSure. “The prior authorization and interoperability proposals we are announcing today would streamline the prior authorization process and promote health care data sharing to improve the care experience across providers, patients, and caregivers – helping us to address avoidable delays in patient care and achieve better health outcomes for all.”

The proposed rule would address challenges with the prior authorization process faced by providers and patients. Proposals include requiring implementation of a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorization. They also include requirements for certain payers to include a specific reason when denying requests, publicly report certain prior authorization metrics, and send decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests, which is twice as fast as the existing Medicare Advantage response time limit. In order to further support a streamlined prior authorization process, this proposed rule would add a new Electronic Prior Authorization measure for eligible hospitals and critical access hospitals under the Medicare Promoting Interoperability Program and for Merit-based Incentive Payment System (MIPS) eligible clinicians under the Promoting Interoperability performance category.

Proposed policies in this rule would also enable improved access to health data, supporting higher-quality care for patients with fewer disruptions. These policies include: expanding the current Patient Access API to include information about prior authorization decisions; allowing providers to access their patients’ data by requiring payers to build and maintain a Provider Access FHIR API, to enable data exchange from payers to in-network providers with whom the patient has a treatment relationship; and creating longitudinal patient records by requiring payers to exchange patient data using a Payer-to-Payer FHIR API when a patient moves between payers or has concurrent payers.

These proposed requirements would generally apply to Medicare Advantage (MA) organizations, state Medicaid and Children’s Health Insurance Program (CHIP) agencies, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs), promoting alignment across coverage types. CMS estimates that efficiencies introduced through these policies would save physician practices and hospitals over $15 billion over a 10-year period.

Finally, the proposed rule includes five requests for information related to standards for social risk factor data, the electronic exchange of behavioral health information among behavioral health providers, improving the exchange of medical documentation between certain providers in the Medicare Fee-for-Service program, advancing the Trusted Exchange Framework and Common Agreement (TEFCA), and the role interoperability can play in improving maternal health outcomes.

The proposed rule is aligned with CMS’ ongoing work to strengthen patient access to care, reduce administrative burden for clinicians so they can focus on direct care, and support interoperability across the health care landscape. It withdraws and replaces the previous proposed rule, published in December 2020, and addresses public comments received on that proposed rule.

For additional information, consult this fact sheet.

The proposed rule is available to review here , and the deadline to submit comments is March 13, 2023. CMS encourages comments from all interested members of the public and, in particular, from patients and their families, providers, clinicians, consumer advocates, health care professional associations, individuals serving and located in underserved communities, and from all other CMS stakeholders serving populations facing disparities in health and health care.

For more information on the CMS proposed rule, please visit: https://www.cms.gov/regulations-and-guidance/guidance/interoperability/index.

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TECH- Google rolls out search features for Medicaid, Medicare patients

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Google seeks to replace your local Medicaid eligibility state employee.

 
 

Clipped from: https://www.fiercehealthcare.com/health-tech/google-rolls-out-search-features-aim-make-it-easier-sign-medicaid-medicare

 
 

LAS VEGAS—When many people are looking to enroll in health benefits, they turn to Google as a source of key information on eligibility, the application process and in-network providers.

In this spirit, the Google Search team has quietly rolled out multiple features for its search engine that aim to make it easier for users to access key information about obtaining Medicaid and Medicare benefits, as well as which doctors locally accept those types of coverage.


(Google)

If someone submits a search query for Medicaid in their state, for example, the top of the results will populate with multiple buttons that direct them to key results on eligibility requirements, how to apply and where they can log in to their accounts. Searching for Medicare generates similar buttons, as well as an option to pull up news about the program.

Hema Budaraju, senior director of product for health and social impact at Google Search, told Fierce Healthcare that access to information is a social determinant of health, and addressing that challenge is a key part of how the tech giant is thinking about equity.

“It’s equity by design in the product,” Budaraju said in an interview at the HLTH conference, “and we’re very proud of being part of the journey.”

Helping people secure coverage is one piece, better enabling them to use it effectively is another. Another recent addition to Google’s search allows people to seek out local physicians and the results will include if those doctors accept Medicare and Medicaid.

When a user clicks into a specific physician, they can also further investigate their options using a “check insurance info” option that allows them to filter by specific Medicare and Medicaid carriers and plans.

Budaraju said the goal was to offer these details in “an easily consumable manner” that enables them to make “timely” decisions about their care and coverage. She added that these tools are not limited to Medicare and Medicaid, and that Google has rolled out similar functionality for the Children’s Health Insurance Program, Supplemental Nutrition Assistance Program and electronic benefit transfer (EBT) programs as well.

The journey in accessing data on these social programs is “nonlinear,” Budaraju said, and often requires people to sift through multiple webpages and sites to find the details they need. That’s why Google saw an opportunity to streamline the experience.

She said the Search team also sees an opportunity to use this framework as a baseline for other scenarios, such as economic security, crisis response or in extreme weather. The focus on equity and easing the user experience is replicable in other areas, she said.

“There is a beauty to understanding, ‘What is the journey?'” Budaraju said.

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Potential Data Disclosure May Have Affected Certain Wisconsin Medicaid Members | Wisconsin Department of Health Services

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Who knew you could fit 12,358 pieces of PHI in a PowerPoint deck?

 
 

The Wisconsin Department of Health Services (DHS) today announced that on August 8, 2022, as part of a cybersecurity incident investigation, DHS was notified that a presentation emailed to the DHS Children’s Long-Term Support Council in April 2021 contained protected health information. This presentation was forwarded to employees working for county government agencies in Rock and other Wisconsin counties and posted to the DHS website as part of the meeting minutes. Information that was potentially exposed includes the first and last name, date of birth, gender, county location, Wisconsin Medicaid member ID number, and social security number of affected members of Wisconsin Medicaid.

After discovering what happened on August 8, 2022, DHS immediately removed the meeting minutes from the website and replaced them with a PDF version, which removed access to the protected health information. Additionally, DHS took steps to confirm that individuals who received the minutes via email deleted the files. DHS will continue to investigate and work to prevent such incidents from occurring in the future.

On October 7, 2022, notifications were mailed to 12,358 Wisconsin Medicaid members whose information may have been accessed by unauthorized individuals. These members have been offered free credit monitoring for one year as well as given access to a dedicated call center to answer questions they might have.

Members who received a notification letter or have questions about this incident can call 833-875-0804 from 8 a.m. to 8 p.m. CT Monday through Friday.

 
 

Clipped from: https://www.dhs.wisconsin.gov/news/releases/100722.htm