James M. Berklan

Providers hoping that policy makers might some day show more backbone when dealing with Medicare Advantage plans can take heart. Well, at least a little.

There are signs that blood is flowing, though it’s not always apparent whether it’s going to the brain or some nether region.

Last week, the Centers for Medicare & Medicaid Services revised the appeals process for Medicare Advantage beneficiaries who have been denied coverage. Finally.

In brief, beneficiaries no longer will be required to pay for the cost of their treatment if they do not appeal quickly enough, nor if their appeal fails. For those who would earnestly file appeals over inconceivable coverage denials, or puzzling short lengths of stay, this is very good news.

As some US lawmakers have tried to impress upon the public and their voting colleagues, Medicare Advantage is neither Medicare nor (often) an advantage. This CMS upgrade tries to bring the MA appeals process more in line with traditional Medicare.

Hey, if you want to shoplift the name, you might as well play by some of its more honorable tenets, right?

The rule also helps a group that’s been stuck between clowns and jokers for too long: Providers. Yes, those who have been “stuck in the middle” of this often Soviet-like appeals process, between the hard-luck beneficiaries in their beds and the MA plans that keep facility staff employed and executives’ bonuses paid.

I’m not sure if the new rules will move the needle much toward prying better coverage out of the MA plans overall. But they might. Currently, MA plan enrollees rarely appeal decisions — likely out of fear of being stuck with a huge medical bill if the appeal is denied, this being the US of Areyoubrokeyet? and all. (And remember who has traditionally adjudicated MA appeals: The same alleged scoundrels who imposed the appealable decision in the first place.)

So there should be more coverage appeals coming, and if form holds, there will be more coverage. There’s no guarantee the appeals success-rate will hold up, but of the relatively few appeals made, north of 80% have been successful. Let’s see how much that rate drops. Maybe not much.

One of the best things of this new era is that fast-track appeals will be reviewed by independent Quality Improvement Organizations rather than the MA plans themselves. Administrative law judges will take center stage again. Or will they?

Maybe the idea of a crush of new appeals won’t be so, well, appealing to the MA plans and their bloated bank accounts. Maybe they’ll decide it’s time to keep potential dirty laundry out of the public eye, and not risk seeing more decisions overturned.

The healthcare universe will be watching, because this is far from the only thing about MA plans that needs changing. If it succeeds, maybe it will lead to a little more courage and wisdom when standing up to the MA juggernaut in the future.

James M. Berklan is McKnight’s Long-Term Care News’ Executive Editor. 

Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.