It will be up to the incoming Trump administration to decide

Medicare Advantage Plans are notorious for denying healthcare treatments to plan subscribers. CMS is intervening by making a much-needed change to how Medicare Advantage plans decides on treatments needed by plan subscribers. Just a couple of pointers showing how MA has been serving it customers . . . the public.

In the existing MA bidding system, any commercial insurer that would like to offer an MA plan submits a plan-specific bid (an amount covering the expected costs of a standard benefit package for an average risk beneficiary) to the Centers for Medicare and Medicaid Services (CMS).What has been occurring? The bids by themselves may be profitable. To gain more profit, MA has been denying claims.

The Inspector General said that “human error” and “system processing error” caused most of the denials by Medicare Advantage plans. But the hospital executives NBC News spoke with say they believe the denials are a strategy by insurers to improve their profits by refusing to pay claims.

To which “little empirical work studies the economics of plan bidding behavior in MA.”

Medicare Advantage Plans’ Prior Auth Rules Would Be Made Public Under CMS Proposal, MedPage Today

Medicare Advantage plans’ prior authorization rules and coverage criteria would become publicly available under a proposed rule issued Tuesday by the Centers for Medicare & Medicaid Services (CMS).

The Biden Harris administration has “worked over the last 3 years to reform the way Medicare Advantage plans can use prior authorization to ensure that patients can access the care they need,” Meena Seshamani, MD, PhD, director of the Center for Medicare, said on a call with reporters.

“Today, we are taking an additional step further to address the inappropriate use of prior authorization.” She continued . . .

“Data reported to CMS by MA [Medicare Advantage] plans indicates that, on average, MA plans overturn 80% of their decisions to deny claims when those claims are appealed to the plan. But these data also show that less than 4% of denied claims are appealed in the first place, meaning that many more denials could potentially be overturned by the plan if they were appealed. And what this means is that more patients could likely have access to care if inappropriate prior authorization did not block it.”

On the call Meena Seshamani told MedPage Today.

The rule would make Medicare Advantage plans’ prior authorization rules more transparent. Plans will need to “clarify what the coverage criteria are and make sure that they are made available to the public. In addition, we are proposing to require the plans provide information on appeals rights to their enrollees . . . So what we are trying to do is both tighten up MA plans’ clinically appropriate coverage criteria, and make sure that people know what those criteria are, and that they know that they can appeal if they have a denial.”

The proposed rule also addresses an issue with provider directories in Medicare Advantage.

“We know that seniors are presented with many options when choosing the Medicare coverage that is best for them. The primary way they evaluate coverage is using Medicare Plan Finder,” said Seshamani. “Based on research and the public input, CMS is proposing . . . the MA organizations make their entire provider directory available to CMS for the purpose of incorporating it into Medicare Plan Finder. This would enable people with Medicare and their caregivers to search for providers and more easily compare their availability across different MA plans. Ensuring that people with Medicare are able to evaluate their coverage and their unique circumstances is critical and helps to empower them to make the right individual choices.”

Sen. Ron Wyden (D-Ore.), chair of the Senate Finance Committee, praised the proposed rule. Saying . . .

“Today’s announcement marks an important step to update and strengthen the Medicare guarantee for Americans. In Medicare Advantage, there are a number of promising actions to limit the overuse of prior authorization, crack down on the prevalence of ‘ghost networks’ that leave seniors unable to find a doctor, and prevent unscrupulous brokers from taking advantage of seniors by enrolling them in a plan that may not work for them.”

The comment deadline for the proposed rule is 5 p.m. on Jan. 27, 2025. It will be up to the incoming Trump administration to decide whether to continue work on the proposed rule.

AB: Not wanting to say anything inappropriate on Angry Bear, it will be a cold day in hell if this proposed rule makes it past the Trump Administration. There is another issue which has been brewing, the USPO. By the time Louis Dejoy is tossed aside, the Post Office will be in serious trouble.

By repeatedly denying claims, Medicare Advantage plans threaten rural hospitals and patients, say CEOs, NBC

COMPETITIVE BIDDING IN MEDICARE ADVANTAGE: EFFECT OF BENCHMARK CHANGES ON PLAN BIDS – PMC