January 25, 2024
ACS advocacy efforts have successfully resulted in the indefinite delay in enforcement of a harmful Blue Cross Blue Shield of Massachusetts (BCBSMA) medical policy that would restrict the use of monitored anesthesia care (MAC) during colorectal and other gastrointestinal procedures. Per this policy, BCBSMA would deny payment for the provision of MAC (e.g., propofol) unless patients undergoing colonoscopies meet specific risk factor or comorbidity criteria.
The ACS, in conjunction with the American College of Gastroenterology (ACG), American Gastroenterological Association (AGA), American Society of Anesthesiologists (ASA), and American Society for Gastrointestinal Endoscopy (ASGE), urged BCBSMA to rescind such policy, stating that limiting coverage for MAC compromises patient safety, delays access to care, and overrides physicians’ clinical judgment. Following strong opposition from these specialty societies, BCBSMA issued guidance on January 24 postponing enforcement of its medical policy until further notice.
Watch Patricia L. Turner, MD, MBA, FACS, ACS Executive Director & CEO, offer context about this important win, which allows surgeons to continue making evidence-based decisions about the way they provide care.
On January 17, the Centers for Medicare & Medicaid Services (CMS) issued its Interoperability and Prior Authorization final rule, which sets requirements related to the electronic exchange of health information and prior authorization processes for government-regulated health plans. For the last several years, the ACS has been urging CMS to finalize many of the requirements contained in this rule.
Starting in 2026, impacted plans must send prior authorization decisions within 72 hours for urgent requests and within 1 week for nonurgent requests. Plans also will be required to disclose specific reasons for denying prior authorization requests and annually publish certain prior authorization metrics, such as approval/denial rates and average processing times, on their public-facing websites.
In addition, CMS will require plans to implement and maintain application programming interfaces (APIs) for prior authorization beginning in 2027. Such APIs must allow providers to complete prior authorization requests via electronic health records (EHRs) and be populated with plans’ lists of covered items and services, as well as documentation requirements for prior authorization approval. APIs will also help facilitate communication about whether a plan approves a prior authorization request (and the date or circumstance under which the authorization ends), denies a prior authorization request (and a specific reason for the denial), or seeks more information from the provider.
Last week, the ACS joined American Medical Association, other national medical organizations, and state medical societies in sending a letter to House and Senate leadership urging Congress to quickly pass legislation stopping the 3.37% Medicare payment cut that went into effect on January 1, 2024.
Congress failed to address this issue at the end of 2023 in the short-term continuing resolution that funded the government until January 19, 2024. Because Congress could not come to an agreement on a longer-term funding package by the January deadline, the House and Senate passed another short-term package that will fund the government until early March.
Over the past 4 years, surgeons have faced a nearly 10% reduction in Medicare reimbursement compounded by rising practice costs. The ACS continues urging key congressional leaders to stop these harmful cuts and consider long-term Medicare physician payment reforms to fix the broken system.