Insights · 2024

2024 Payer Clinical Policy Perspective

Clinical policies are becoming vital tools, more so than ever, for establishing care best practices and managing utilization.

Overview of the Clinical Policy Landscape in 2024

Clinical policies are becoming vital tools, more so than ever, for establishing care best practices and managing utilization.

Our perspective is that payers will need to reinvent their approach to medical management to meet CMS interoperability and PA rules, patient and public criticism and market demands over the next 2 years.

This perspective is grounded in the following observations:

Policies manage a substantial 20-40% of medical spend through policy, yet alignment across payers remains low (10-50% overlap between payers), presenting opportunities for improvement.

Recent policy trends focus on oncology (e.g., ablation), ophthalmology (e.g., glaucoma surgery), and immunotherapy medications (e.g., Benlysta), often spreading across payers in waves with 2-3 months.

Medicare Advantage (MA) policies are gaining prominence, with large payers like Humana and UHC now maintaining 100+ MA policies.

CMS policy activity has been limited (2 policies this year), but the Interoperability and PA Final Rule (CMS-0057-F) will disrupt the process in which clinical policy is adjudicated in prior authorization, requiring real modernization of policy criteria and the process.

Public scrutiny over payer denials highlights reputational and ethical risks of outdated policies not aligned with peers or evidence-based guidelines. This creates an urgent need for payers to align policies to peers, monitor trends, and modernize practices

Opportunities in the Space for 2025

Opportunities for Payers in 2025

Rapidly assess the current policy portfolio to ensure alignment with peers and evidence-based guidelines to mitigate reputational and ethical risks related to unfounded denials

Identify opportunities through competitive intelligence to bridge gaps in policy to avoid inappropriate and unnecessary utilization

Stand-up an enterprise-wide effort, led with a collaboration of medical management and technology teams, to meet the incoming deadlines of the CMS Interop. And PA rule

Opportunities for Providers in 2025

Integrate clinical policy into provider workflows to understand payer expectations and refer to the policy as helpful to inform optimal care for patient

Identify opportunities to leverage the interoperability APIs (e.g., leveraging the provider API for seamless patient onboarding and care planning)

1. Payers are using clinical policies to manage 20-40% of their spend

Commercial spend managed by payer policies, ($ PMPM)

•Clinical policy covers cover 20-40% of all Commercial spend
•Across a subset of large payers, there is a difference of over $150 PMPM being managed between the most comprehensive payer policies and the most narrow
•Opportunity: Payers should review their policies (both the broad ones and narrow ones) to ensure alignment to market

1. Across payers variation is evident when comparing policy overlap between payers

Overlap of policy between payer pairs,
(% of LHS payer policies that overlap with column payer's policies)

	Aetna	Anthem	BCBSMA	BCBSNC	BCBSSC	Cigna	HCSC	Humana	UHC
Aetna		33	10	12	26	15	25	13	15
Anthem	42		13	15	27	18	25	10	16
BCBSMA	19	21		26	43	10	43	6	5
BCBSNC	34	33	40		67	23	48	22	17
BCBSSC	36	27	28	29		15	37	16	15
Cigna	20	16	6	7	13		13	9	11
HCSC	43	36	42	30	53	19		14	19
Humana	48	25	11	22	39	29	26		25
UHC	48	39	10	17	33	25	35	21

•There is a wide variation in policy overlap amongst payers
•Blues tend to have high overlap due to leveraging shared Association policies
•Opportunity: Understanding gaps in overlap is fundamental to realizing gaps in policy coverage

2. Recent payer policy activity has been focused across a few clinical themes

Non-exhaustive examples

Advanced tumor ablation and radiation therapies for oncologic and non-oncologic conditions

Aetna: Radiofrequency Tumor Ablation
Humana: Radiofrequency Tumor Ablation

Glaucoma and related ophthalmic surgical interventions through comprehensive treatment and testing policies

Aetna: Glaucoma Surgery (last reviewed 11/2024)
United: Glaucoma Surgical Treatments (effective 1/2025)
Cigna: Glaucoma Surgical Procedures (effective 10/2024)

Advanced immunotherapies and biologics for autoimmune and oncological conditions

Anthem: Benlysta (published 9/2024)
Aetna: Benlysta (published 10/2024)
UHC: Benlysta (published 11/2024)

Hematopoietic stem cell transplantation for various malignancies and autoimmune conditions

Humana: Hematopoietic Stem Cell Transplantation (effective 7/2024)
HCSC: Hematopoietic Cell Transplantation for Autoimmune diseases (effective 11/2024)

Advanced cardiac monitoring and treatment technologies, including devices and electrophysiological procedures

Cigna: Ambulatory External and Implantable Electrocardiographic Monitoring (effective 11/24)
Humana: Ambulatory Cardiac Monitoring Devices (effective 7/25)

3. MA policy has been ramping up, especially amongst the nationals and large payers

Non-exhaustive examples

Payer

Number of MA policies (#)

MA spend managed, ($ PMPM)

Humana

154

$194

United Healthcare

$109

Blue Cross Blue Shield of Michigan

N/a

4. CMS new NCD policy activity was limited, but the Interoperability and PA Rule could be disruptive

New NCD policies, (#)

CMS Interoperability and Prior Auth Rule Overview

The Centers for Medicare & Medicaid Services (CMS) issued the Interoperability and Prior Authorization Final Rule (CMS-0057-F) on January 17, 2024, aiming to enhance health information exchange and streamline prior authorization processes.

Key Provisions:

Patient Access API: Impacted payers must expand their existing Patient Access APIs to include prior authorization information (excluding drugs) by January 1, 2027.This enables patients to access more comprehensive health data.

Provider Access API: By January 2027, payers are required to implement a Provider Access API, facilitating data sharing with in-network providers who have a treatment relationship with the patient. This includes claims, encounter data, and prior authorization details.

Payer-to-Payer API: To support care continuity, payers must establish a Payer-to-Payer API by January 1, 2027, allowing the exchange of patient data.

Prior Authorization API: Payers are mandated to implement a Prior Authorization API by January 1, 2027, to automate and expedite prior authorization requests and responses, improving efficiency for providers and patients.

Prior Authorization Decision Timeframes: Payers must adhere to decision timeframes: 72 hours for expedited requests and 7 calendar days for standard requests

Public Reporting of Prior Authorization Metrics: Payers are required to publicly report certain prior authorization metrics annually

Compliance deadlines vary, with operational provisions generally effective January 1, 2026, and API requirements by January 1, 2027

About Us

NOF1 is a payer policy intelligence platform across clinical and reimbursement policies. Our goal is to transform the way payers, providers, and other stakeholders navigate the complex landscape of healthcare policy to transform the way healthcare is delivered.

Our portfolio of products include:

For payers:

A competitive intelligence platform with over 10K+ clinical policies across payers, UM vendors and CMS. Designed for payers to assess their policy positioning, rapidly research alignment and differences relative to peers.

For providers:

An EMR platform that allows providers to understand clinical policy requirements at point of care, drastically improving documentation quality and compliance while reducing unnecessary denials.

For all stakeholders:

APIs that allow the retrieval of clinical policies in machine readable form and criteria to allow for integration into your enterprise software

To learn more, please reach out to ahmed@nofone.io