Overview

The Centers for Medicare & Medicaid Services (CMS) has finalized the Interoperability and Prior Authorization Final Rule, which introduces major updates to streamline prior authorization processes, improve payor communication, and reduce administrative burden for providers. These changes impact Medicare, Medicare Advantage, and other federally qualified health plans.

Prior authorizations are one of the leading causes of denied claims, costing healthcare providers millions in lost revenue every year. With the growing complexity of payer requirements and documentation, it is critical that your practice understands and implements these CMS updates correctly to avoid reimbursement delays, compliance issues, and disruption in patient care.

In this 90-minute webinar, healthcare attorney and compliance expert Osato Chitou, ESQ., MPH, will provide practical guidance, tips, and actionable strategies for navigating the prior authorization landscape. Participants will gain insights into faster approval processes, reducing denials, and leveraging interoperability solutions to streamline workflow and enhance revenue cycle efficiency.

Why You Should Attend

Healthcare organizations often face challenges with prior authorizations, such as:

• Delays in obtaining payer approval

• Denials for services that should be covered under Medicare

• Burdensome documentation requests

• Impact on patient care and satisfaction

The new CMS Interoperability and Prior Authorization Rule addresses these issues by mandating electronic prior authorization processes, streamlined workflows, and improved transparency. By attending this session, participants will:

• Understand updated CMS prior authorization requirements

• Learn how to speed up approvals and reduce claim denials

• Gain knowledge about payer-specific rules and electronic workflows

• Implement best practices to mitigate prior authorization risks

• Optimize revenue cycle performance and patient care efficiency

This session is designed for executives, compliance officers, revenue cycle staff, and clinicians who are responsible for prior authorization processes and payer interactions.

Learning Objectives

By the end of this webinar, participants will be able to:

1. Understand the updated CMS prior authorization guidelines and their impact on providers

2. Identify which services, procedures, and medications commonly trigger prior authorization

3. Implement strategies for faster approvals and reduced claim denials

4. Navigate payer-specific processes, portals, and electronic transactions

5. Track and monitor prior authorization metrics and KPIs

6. Conduct internal audits to identify bottlenecks and improve workflow efficiency

7. Apply best practices for interoperable data exchange using Patient Access, Provider Access, Payer-to-Payer, and Prior Authorization APIs

8. Prepare your practice for 2024 compliance deadlines and CMS enforcement requirements

Detailed Areas Covered

1. Prior Authorization Requirements

• Overview of CMS mandates and compliance obligations

• Impact of prior authorization on revenue cycle management

• Key documentation and coding requirements for accurate submissions

2. CMS Interoperability and Prior Authorization Final Rule

• Objectives and scope of the Final Rule

• Mandates for Medicare, Medicare Advantage, and other federal plans

• Integration of HL7® FHIR® APIs for electronic data exchange

• Enhancing workflow efficiency and patient care through interoperability

3. APIs and Electronic Transactions

• Patient Access API: Enabling patients to access prior authorization status

• Provider Access API: Streamlined provider access to submission and response data

• Payer-to-Payer API: Facilitating coordination between payers for seamless approvals

• Prior Authorization API: Automation and electronic submission of requests

4. Improving Prior Authorization Processes

• Techniques to reduce administrative burden and speed approvals

• Leveraging technology and electronic submissions for compliance

• Identifying and eliminating inefficiencies in workflows

5. Prior Authorization Metrics and Audits

• Tracking approval and denial timelines

• Analyzing reasons for delays and denials

• Conducting internal audits to optimize processes

6. Choosing the Right Prior Authorization Method

• Standard electronic transactions vs payer portals vs multi-payer portals

• Fax, telephone, and secure email processes

• Aligning workflow with payer requirements for maximum efficiency

7. CPT Codes, Medications, and Triggers

• Identifying services and procedures that require prior authorization

• Categories of medications commonly subject to prior authorization

• Strategies to prevent unnecessary denials

8. Best Practices to Mitigate Denials

• Clear submission documentation and proactive follow-up

• Effective communication with payers to reduce delays

• Implementation of checklists and internal protocols for consistency

9. Compliance and Enforcement

• Understanding CMS enforcement priorities

• Ensuring your practice meets regulatory standards

• Minimizing exposure to penalties and revenue loss

Suggested Attendees

This webinar is highly valuable for:

• Healthcare Executives and Administrators

• Compliance Officers and Legal Counsel

• Medical Practice Managers and Department Managers

• Physicians, Nurses, and Clinical Staff

• Revenue Cycle Staff, Billing, and Collections Teams

• Front Desk, Scheduling, and Authorization Staff

• IT Professionals managing healthcare interoperability

• Any member of the practice involved in prior authorization or payer communications

Benefits of Attending

Participants will leave this session with:

• Clear understanding of CMS Interoperability and Prior Authorization Final Rule 2024

• Practical knowledge to accelerate approvals and reduce claim denials

• Insight into payer-specific rules, APIs, and electronic submission methods

• Tools to optimize internal workflows and improve revenue cycle efficiency

• Strategies to mitigate risk and enhance compliance for both clinical and administrative teams

• Real-world guidance to streamline prior authorization and improve patient care