MHA Today | December 7, 2022

CMS released a proposed rule that would “streamline processes related to prior authorization for medical items and services.” The rule also includes proposals to increase health data exchange through interoperability. The prior authorization proposals would apply to Medicare Advantage organizations, state Medicaid and Children’s Health Insurance Program fee-for-service programs, Medicaid managed care plans and CHIP managed care entities, and Qualified Health Plan issuers on the Federally Facilitated Exchanges. The major prior authorization improvement proposals include the following.

• requiring payers to build and maintain a Health Level 7 Fast Healthcare Interoperability Resource standard Application Programming Interface that would automate the process for providers to determine whether a prior authorization is required
• compelling payers to provide a specific reason when a prior authorization is denied
• decreasing the prior authorization timeframes to 72 hours for expedited requests and seven calendar days for standard requests
• requiring payers to publicly report certain prior authorization metrics on the payer’s website

Comments about the proposed rule are due March 13, 2023.

Pfizer and BioNTech submitted an application to the FDA for EUA of their Omicron BA.4/BA.5-adapted bivalent COVID-19 vaccine as the third 3-µg dose in the three-dose primary series for children ages 6 months through 4 years. Pfizer is taking this action due to the high level of respiratory illnesses circulating among children to help reduce the burden on the health care system.

Missouri hospitals currently are experiencing an increase in hospitalizations due to viral respiratory illnesses resulting in strain on EDs, throughput and inpatient capacity. In response to hospital requests for increased situational awareness of bed capacity across the state, and to monitor and address potential impacts to statewide health care operations, MHA is launching a daily bed availability query in EMResource beginning Thursday, Dec. 8, from 7 to 10 a.m. for all Missouri and Kansas City, Kan., metro hospitals.

MHA will continue to monitor bed availability impacts and maintain direct communication with hospital and statewide advisory contacts to determine the appropriate point at which to end the daily inquiries. The information collected will be monitored daily by hospitals looking for patient placement and will serve as a critical, early indicator of specific hospital operational issues, and also as an indicator of regional trends that may require more significant response and mitigation efforts.