In today’s digital age, healthcare’s reliance on technology has become a double-edged sword. A recent cyberattack on Change Healthcare exposed vulnerabilities that rippled through the industry, disrupting payments and patient care. Amid this chaos, another longstanding issue resurfaced: the cumbersome prior authorization process in Medicare Advantage. CMS Administrator Chiquita Brooks-LaSure stepped up to address both challenges, outlining reforms and support measures that signal a new era of resilience and patient-centric care. 

All About the Cyberattack on Change Healthcare 

The cyberattack on Change Healthcare, a subsidiary of UnitedHealth Group, has had far-reaching consequences for healthcare providers across the country. The attack disrupted critical operations, including payment processing, and the exchange of clinical records. This disruption has been particularly challenging for smaller practices operating on thin margins. 

CMS Response to the Cyberattack on Change Healthcare  

CMS Administrator Chiquita Brooks-LaSure has acknowledged the severity of the situation, stating that the Cyberattack on Change Healthcare was a significant event that caught many off guard. In response, CMS has been working closely with affected providers and suppliers, offering guidance and support to mitigate the attack’s impact.

One of the key measures announced by CMS is the provision of flexibility to states, allowing them to support Medicaid providers and suppliers during this difficult time. This includes urging Medicaid-managed care plans to make prospective payments to impacted providers.  

Prior Authorization Reforms in Medicare Advantage 

A 2022 report from the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) revealed that Medicare Advantage Organizations were impeding enrollees’ access to necessary healthcare through delays and denials. This process, used by health plans to determine coverage for prescribed services, has long been contentious.

• CMS’s Reforms to Prior Authorization: After the 2022 OIG report, CMS implemented reforms in April 2023 and January 2024 to reduce care delays and inappropriate denials in Medicare Advantage. These changes align with CMA’s advocacy. CMS Administrator Brooks-LaSure emphasized ongoing efforts to monitor and improve the process industry-wide. 
• Financial Impact of Reforms: The reforms introduced by CMS are expected to yield substantial savings for physician practices. CMS estimates that the efficiencies brought about by these policies will save physician practices over $15 billion over 10 years. These savings highlight the positive financial impact of reducing administrative burdens associated with prior authorization. 
• Ongoing Challenges and Future Actions: Despite these reforms, challenges remain. Brooks-LaSure noted that CMS continues to hear from patients and providers about commercial insurer prior authorization denials and delays. “The volume of frustration has just exploded,” she said, indicating the widespread nature of this issue. 
• Potential Focus on Prescription Drugs: Brooks-LaSure also signaled that prescription drugs could be a potential area for further action. “I’ve been hearing a lot about prescription drugs,” she said, suggesting that CMS is evaluating whether additional reforms are necessary to address prior authorization issues related to medications. 
• Collaboration with Stakeholders: CMS encourages health plans to innovate solutions alongside federal regulations. CMS also supports congressional and state-level reform efforts. CMA continues advocating for extending reforms to prescription drugs and ensuring timely patient care, reflecting a multi-faceted approach to improving prior auth processes. 
• CMA’s Role in Prior Authorization Reforms: The California Medical Association (CMA) has been a key advocate for prior authorization reforms. CMA continues to work with Congress on federal legislation to achieve remaining prior authorization goals and is urging CMS to include drugs in its reform efforts. Additionally, CMA supports state-level legislation to ensure timely patient care access. 
• Promoting Transparency in Prior Authorization Criteria: CMS has prioritized transparency in prior authorization criteria across Medicare Advantage, Medicaid, and CHIP programs. New regulations finalized earlier this year aim to streamline the process and reduce providers’ administrative burden, which is particularly crucial in light of a recent cyberattack that compounded existing challenges. 
• Supporting Providers During the Cyberattack: In light of the cyberattack, CMS has taken additional steps to help providers. This includes encouraging Medicare Advantage organizations to offer advance funding to affected providers and ensuring that Medicare Administrative Contractors can accept paper claims. Providers are also advised to contact their contractors for details on exceptions, waivers, or extensions if they encounter difficulties filing claims. 

The Path to Resilient and Patient-Centric Healthcare 

CMS’s proactive response to the Cyberattack on Change Healthcare and prior authorization challenges underscores the value of centralized communication and collaboration in healthcare. CMS aims to create a more resilient, efficient system by fostering transparency, implementing reforms, and engaging stakeholders. This collaborative approach is key to reducing administrative burdens, enhancing patient care, and adapting to evolving challenges. 

Streamline your prior authorization process with DocToc’s virtual medical assistants. Our HIPAA-certified, secure, and confidential services offer end-to-end solutions that minimize write-offs and denials. With competitive rates and quick processing times, we ensure speedy documentation and high approval rates. Our dedicated team provides diligent follow-up until resolution, treating every account with equal importance regardless of size, age, or claim value. We expedite the authorization process and conduct periodic follow-ups to maintain validity.

By partnering with DocToc, clinics can reduce administrative burden, improve efficiency, and focus on patient care. Contact DocToc today to experience seamless prior authorization services that enhance your practice’s productivity and financial performance.