2023 Regulatory Outlook for Physician Groups: Five Key Issues to Follow
Towards the end of 2022, the Centers for Medicare and Medicaid Services (CMS) introduced more than 5,000 pages of new rules, and the U.S. Congress passed a spending bill of over 4,000 pages, with over 1,000 pages dedicated to healthcare provisions. It’s no surprise that many doctors are still sorting through all of this paperwork to figure out how these new laws and regulations will impact them.
Now that it’s January and a new year has begun, it’s an excellent time to look forward and anticipate what’s on the horizon. With a new Congress and several key regulatory initiatives already underway, there are several top regulatory issues that physician groups should keep an eye on in 2023.
1. Prior Authorization
Physicians have expressed frustration with the prior authorization process, citing it as a major source of burnout and job dissatisfaction. To address these concerns, the government is proposing new regulations to streamline the process and digitize it further. The proposed rule, released by CMS in December, focuses on electronic prior authorization and includes several new API requirements for payers in government-sponsored programs. The proposed rule aims to automate the prior authorization process, making it easier for providers to submit requests and receive decisions. Providers would be required to report on electronic prior authorization measures as part of the MIPS Promoting Interoperability category starting in 2026. The ONC is expected to release a proposed rule related to EHR certification requirements for this new prior authorization process, which would have implications for certified EHR companies and their clients.
2. Price Transparency and Cost Estimate Mandates
The 2020 No Surprises Act requires healthcare providers to offer patients detailed pre-visit cost estimates in an effort to boost transparency and eliminate surprise medical bills. Providers must provide good faith cost estimates to uninsured or self-pay patients, but enforcement of co-provider and co-facility requirements has been delayed. The CMS has also delayed requirements for providers to share data with payers to furnish a pre-visit advanced explanation of benefits document to insured patients intending to submit claims. CMS has cited a lack of data standards and interoperability as the reason for these delays. In 2023, CMS is expected to issue rulemakings to implement these outstanding No Surprise Act requirements, which will create new financial data-sharing standards and processes important for providers, insurers, and technology companies.
3. Next Stage of Cures Act Data Sharing Rules
The 21st Century Cures Act law aimed to improve health data interoperability through three key policies: EHR certification program updates, information blocking, and the trusted exchange framework. These policies have been gradually implemented over the past few years, but in 2023 there will be major movement, including a requirement for the 2015 Edition Cures Update to be the only certified EHR technology accepted in federal programs. The opening of the application portal for prospective Qualified Health Information Networks (QHINs) is also expected to lead to QHIN approvals, signings of the Common Agreement, and operational data exchange. In 2023, HHS is expected to finalize its penalty and enforcement policies related to information blocking, which will trigger a new compliance deadline for providers. ONC is also set to release proposed regulatory updates for each of its major Cures Act policies in early 2023.
4. Implementation of once -in-a Decade ACO Forms
The regulations governing Medicare’s Shared Savings Program (MSSP), which is the largest Accountable Care Organization (ACO) program, were changed last year to increase program participation. These changes included providing additional time for ACOs to participate in the program without taking on downside risk and offering risk-free advance shared savings payments to certain types of new ACOs. The success of these changes in increasing physician participation will be seen during the 2023 application cycle. These changes may also cause physician groups to reassess their ACO strategies, form new partnerships or models, and explore opportunities with other payers besides Medicare.
5. Bipartisan Telehealth, Behavioral Health, and Medicare Payment Laws
With the 118th Congress now in session, there is curiosity about the new healthcare laws that will be created with a divided Congress. Since Republicans control the House and Democrats control the Senate, bipartisan support is necessary for any legislation to become a law. As a result, healthcare policies that only have one political party’s backing will not pass. However, the current Congress has an opportunity to pass meaningful bipartisan legislation on issues such as Medicare payment reform, telehealth, and behavioral health. Although the previous Congress addressed some of these issues in a 4,000-plus-page spending bill passed in December, the reforms were temporary. Therefore, the current Congress has a chance to build on the bipartisan efforts of last year and pursue more comprehensive and permanent reforms in these areas, which could significantly affect physician groups if passed into law.
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