INSURANCE

Reducing the number of services requiring prior authorization will ensure timely patient care

Major U.S. health insurers—including UnitedHealthcare, CVS/Aetna, Cigna, Humana, Elevance Health, and Blue Cross Blue Shield—have announced a sweeping initiative to streamline and simplify the prior authorization (prior approval) process across commercial, Medicare Advantage, and Medicaid managed care plans. This move is expected to impact approximately 257 million Americans.

Common procedures like imaging, physical therapy, colonoscopies, cataract surgeries, and outpatient surgeries are among those targeted for fewer prior authorization requirements.  By 2027, 80% of all prior authorization requests are expected to be processed in real time, leveraging standardized electronic submissions and advanced automation, including artificial intelligence. This is a major shift from the current system, where approvals can take days or longer.

All clinical denials will be reviewed by qualified medical professionals, ensuring that decisions are based on appropriate clinical judgment rather than automated or non-clinical review.

Providers have long criticized the use of prior authorization to keep patients in need of skilled care out of nursing homes, or to reduce their length of stay against their doctor’s wishes or care plans.

Congress is considering the bipartisan Improving Seniors’ Timely Access to Care Act, which would codify many of these reforms for Medicare Advantage and further reduce administrative burdens for providers.

The reforms are designed to make prior authorization faster, simpler, and more patient-friendly, though providers and advocates will be monitoring implementation closely to ensure these commitments result in real-world improvements.

REGULATORY PRIORITIES

Infection control is now a central focus in enforcement efforts

Infection control has become a central focus in nursing home enforcement due to persistent risks, regulatory priorities, and the high stakes for resident safety. Several key factors explain this heightened emphasis.

1. Vulnerable Resident Population
Nursing homes serve older adults and individuals with chronic health conditions, who are especially susceptible to healthcare-associated infections (HAIs). Residents often live in close quarters, making outbreaks more likely and more dangerous.

2. High Rate of Infection Control Deficiencies
Infection control violations have been among the most frequently cited deficiencies in recent years. In 2024 alone, over 12,000 F-tag 880 violations were cited, with a significant number resulting in actual harm or immediate jeopardy for residents.

These deficiencies can lead to preventable outbreaks, serious illness, and even death, underscoring the need for strict oversight and rapid corrective action.

3. Lessons from the COVID-19 Pandemic
The pandemic exposed critical gaps in infection prevention and control practices in long-term care settings, resulting in high morbidity and mortality. This has led CMS and the CDC to make infection control a permanent, top-tier regulatory priority.

4. Regulatory and Enforcement Changes

• For 2025, CMS has explicitly prioritized infection prevention and enhanced barrier precautions in its survey protocols and enforcement actions.
• Facilities are now required to strengthen their Infection Prevention and Control Programs (IPCPs), with an emphasis on staff training, outbreak management, and real-time infection reporting.
• Enhanced enforcement mechanisms include higher penalties for noncompliance, more frequent inspections for low-performing facilities, and stricter monitoring of infection control practices.

5. Data-Driven Quality Improvement

• The National Healthcare Safety Network (NHSN) now plays a central role in tracking and benchmarking infection rates in nursing homes. Facilities are expected to use NHSN data to identify trends, implement targeted interventions, and demonstrate compliance with federal standards.

• Transparent reporting and benchmarking help facilities set and achieve evidence-based infection control goals, improving outcomes for residents.

6. Operational and Financial Implications
Infection outbreaks are costly, leading to increased hospitalizations, regulatory penalties, and reputational damage. Effective infection control is not only a compliance issue but also essential for operational efficiency and financial sustainability.

Infection control is now central to enforcement because it directly impacts resident safety, has been a consistent area of deficiency, and is critical for preventing costly, deadly outbreaks. Regulatory agencies have responded with stricter rules, enhanced penalties, and a data-driven approach to ensure that nursing homes prioritize robust infection prevention and control at every level of care.

THE EXCELAS TEAM: SHARON EZZONE

Meet the Excelas Team! Starting with our Vice President of Operations and Human Resources – Sharon Ezzone

Sharon began her career as an Operations Manager at Evant, Inc., managing long-term care facilities. Sharon then transitioned into Human Resources, holding key roles at Swagelok Company, Education Solutions, LLC (dba Sylvan Learning Centers), Cleveland Clinic, and Giesecke & Devrient America, Inc. For the past 10 years, Sharon has led Human Resources and Operations at Excelas, LLC, earning accolades such as Northcoast 99, When Work Works, Best Employers in Ohio, and Best & Brightest in the Nation.

Outside of work, Sharon is a patron of the Cleveland Museum of Art, The Cleveland Orchestra, and Playhouse Square. She enjoys art, live music, theater, traveling, hiking, staying fit, and spending time on Hilton Head Island, SC with family and friends. Sharon supports her blended family, which includes four children and two grandchildren.

Excelas helps organizations respond accurately and quickly to claims and litigation brought against them

Partnering with attorneys, health care organizations, and insurance companies since 1995, Excelas provides medical legal analyses and tools for building winning defense strategies. When expertise, accuracy, reliability, and on-time delivery count, you can count on Excelas.

You can always read all our newsletters online!