On July 8, 2025, I had a blog discussing the CMMI plan to introduce Prior Authorization into Medicare Part B. Prior-auth companies would bid for the right to interpose their Prior Auth software between the provider and the MAC. I noted (and you had to dig for this) that the Prior Auth companies would be paid based on charges avoided (ie, the volume of denials they could generate.)
I also noted that the PA computers were supposed to simply implement the rules for existing LCDs/NCDs, but that some of the topics to be authorized actually had no meaningful guidance at CMS.
Some follow-up a month later.
At Linked In, Brian Miller highlights the potential problems, pointing us to a new Op Ed by Donald Berwick and Andrew Ducas.
See the STAT article by Berwick & Ducas here.
See also an opinion piece by Jessica Hall at Marketwatch here.
