AHA Urges CMS to Correct Medicare Advantage Plan 2024 Rule Violations
With this particular American Hospital Association letter, I pulled out the particular points in which the AHA is pointing out and filing complaints. The balance of the letter can be found at the link above, in the title (below), or in the attached PDF file at the end of this post. Unfortunately, it is too long in making its legitimate points.
Insurance typically have a delay in payment which is normal fact. Every plan has different rules for which each healthcare facility must meet. Hence greater Overhead. The MA plans (some?) go well beyond what is typical with everyday healthcare plans.
If you go to a hospital for care, they can keep you for two days in the hospital for observation and then they have to release you or admit you. If they do not admit you and you stay there for observation, Medicare will not pay what it normally pays.
I find this competition between Traditional Medicare and Medicare Advantage to be tiresome. The MA Plans are subsidized, and they pull funds from Traditional Medicare. The bonuses + costs exceed what Traditional Medicare would pay out. The care is not any better and can be less than what Traditional Medicare provides at a lesser cost. Thiis does not mean that Traditional Medicare can not be improved. The Commercial version of Medicare is profit motivated and predatory. Medicare Advantage is a business.
The points I pulled out are below. I hope you read the AHA’s complaints about Medicare Advantage’s deliberate practices.
AHA Urges CMS to Swiftly Correct Medicare Advantage Plan Policies That Appear to Violate CY 2024 Rule | AHA
Compliance to New Rules and Pathways for Escalation and Resolution of Violations Identification
Compliance to New Rules:
Business as Usual regardless of CMS 2024 rules: Given the broad and far-reaching changes finalized in the CY 2024 MA rule, it is striking that several large, national MAOs would report to our members that they do not intend to make any modifications to their utilization management protocols in response. In the proposed and final rules, CMS thoughtfully articulates and seeks to address a variety of circumstances in which existing rules are not being followed or services that would have been covered under Traditional Medicare that are being routinely denied by MAOs. We are troubled that certain MAOs may interpret the final rule as to not require them to make any changes to their practices. At least one plan reports that they still do not believe the Two-Midnight rule applies to them as an MAO, which directly contradicts our understanding and reading of the CY 2024 final rule.
contradict CMS’ stated intent in the final rule that MAOs must adhere to: In other cases, we have observed changes in certain MAO denial letters (shared with us by members) that appear to directly contradict CMS’ stated intent in the final rule that MAOs must adhere to the Traditional Medicare coverage criteria for inpatient admissions (e.g., the Two-Midnight rule, the Inpatient Only List, or the case-by-case exception). Specifically, members have reported that certain plans are retroactively reviewing inpatient stays that received prior authorization citing that they are not doing so as a medical necessity audit but rather under a short stay audit that is performed on any inpatient Medicare stay that is less than two days. We understand that the Two-Midnight presumption does not apply but the criteria by which the plan is required to review the inpatient stay retroactively should be against the Traditional Medicare criteria for inpatient admission (specifically, the Two-Midnight rule) — not the criteria of a short stay policy of the plan’s own making. This appears to us as a direct contraction of the requirements included in the CY 2024 MA final rule. As a result, we encourage CMS to provide further direction and guidance to MAOs leading up to implementation.
circumvent CMS rulemaking under the auspice that this is a payment issue not subject to CMS interference, as opposed to a coverage determination.: For example, a member hospital received a denial letter from an MAO, on behalf of a third-party vendor, for a short stay audit for inpatient care noting that they conducted a “payment integrity administrative review, not a level of care or a medical necessity review, focused on payment of services.” The letter goes on to say that the plan “is not denying the services provided, rather the review is focused on the payment of services documented in the medical record.” It is unclear to us how such an audit — which is determining whether inpatient care was appropriate — would not be a level of care or medical necessity review, which by definition would constitute an organizational determination subject to CMS rules.
Delay of Payment Policy: MAO has a published, publicly available policy of responding to appeals within 60 days of a provider filing a dispute after receiving an adverse benefit or payment determination. In February, the health system reported 140 outstanding appeals with this MAO alone — all of which are for MA beneficiaries — that are greater than 60 days old where they have not yet received a response from the plan. The MAO has acknowledged that they are behind but has not made any tangible progress in addressing the backlog of cases despite the health system’s efforts to escalate. As of September 2023, not only has the backlog of appeals not been addressed, but it has grown to 189 cases that are over 60 days old, approximately 50% of which are from 2022. In the meantime, the MAO withholds payment for the services in question, even when historical appeal success rates evidence that the denials are likely to be overturned.
Hiding denials of payment: another example of insufficient dispute resolution processes and challenges escalating issues with a large, national MA plan, a member hospital recently shared data with AHA about an MAO issue affecting 175 inpatient stays dating back to 2020, which remain fully unpaid by the MAO as a result of pre-payment clinical validation audits. Not only are these unpaid accounts for services rendered to patients, but these cases are really denials (for which the hospital received $0 of payment) that are disguised as contractual adjustments. In other words, the MAO system adjusted the entire balance of these accounts to zero as a contractual write-off and did not identify any amounts as denials. This prevented these claims from hitting the hospital’s denial workflow, leaving them undiscovered for several months. Additionally, it results in these claims not appearing as denials in any reporting, which precludes appropriate and transparent oversight.
Pathways for Escalation and Resolution:
Delays in addressing Appeals: The MAO has a published, publicly available policy of responding to appeals within 60 days of a provider filing a dispute after receiving an adverse benefit or payment determination. In February, the health system reported 140 outstanding appeals with this MAO alone. All of which are for MA beneficiary appeals are greater than 60 days old and where they have not yet received a response from the plan. The MAO has acknowledged that they are behind but has not made any tangible progress in addressing the backlog of cases despite the health system’s efforts to escalate. As of September 2023, not only has the backlog of appeals not been addressed, but it has grown to 189 cases that are over 60 days old, approximately 50% of which are from 2022. In the meantime, the MAO withholds payment for the services in question, even when historical appeal success rates evidence that the denials are likely to be overturned.
Delays of Payment: The inability to resolve 175 claims for services provided to patients that have gone entirely unpaid by an MAO for nearly three years suggests that current dispute resolution mechanisms are inadequate to ensure appropriate oversight of MAOs. After a year and a half of chasing the MAO and trying to resolve the issue with the plan directly, including written communications demonstrating that payment was supported for each account after the plan’s DRG reduction recommendation, the hospital was successful in securing partial payment for only two of the 175 accounts, without any interest.
American Hospital Association (AHA) Urges CMS to Swiftly Correct Medicare Advantage Plan Policies That-Appear-to-Violate-CY-2024 Rule.pdf