Medicare Advantage documents

Forty-five days after proposing changes that attempt to rein in some of the most-criticized practices of Medicare Advantage plans, federal officials now must filter through nearly 1,000 formal comments.

Comments shared by two major organizations representing long-term care providers, in addition to a partial review of feedback publicly available through the Federal Register, show that healthcare providers are hungry for more oversight and changes that will keep post-acute options open to MA beneficiaries.

“This proposed rule appears to acknowledge that we are at a critical juncture as Medicare Advantage enrollment is nearing 50% of all enrollees,” LeadingAge said in its 20-page response to the Centers for Medicare & Medicare Services’ proposed rule for Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program. “If we don’t ensure proper beneficiary protections and program improvements now, it may become too late.”

In part, the CMS proposed rule aims to ensure that Medicare beneficiaries who select MA plans still have equitable access to traditional Medicare Part A & B benefits. Providers have long argued that plans push patients into less-intensive, and often less expensive, care levels faster than their peers who maintain fee-for-service coverage.

LeadingAge asked CMS to go beyond its proposal’s initial protections and “further clarify the breadth and scope of post-acute care services to be covered.”

“We want to ensure MA enrollees’ access includes up to 100 days of skilled nursing care (when medically necessary) and coverage for all medically necessary, 30-day home health episodes, as is permitted under traditional Medicare,” wrote Nicole Fallon, vice president of health policy and integrated services.

The organization also indicated that its members had reported an increase in plans denying care for care in the case of patients for whom treatment would preserve function, rather than improve it. Fallon asked CMS to highlight that plans are prohibited from denying coverage for “lack of progress.”

“The restoration potential of a patient is not the deciding factor in determining whether skilled services are needed,” Fallon wrote, noting a long-fought legal battle that won skilled nursing patients the right for continuity care. “Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities.” 

In its letter, the American Health Care Association / National Center for Assisted Living said it supported increased oversight and strengthening of MA prior authorization processes.

“AHCA/NCAL member providers have seen significant increases in aggressive utilization management tactics resulting in access to care and cost issues for beneficiaries as well as increasing administrative burden for providers,” the association said in its 19-page comment letter. “The proposed changes from CMS will work to lessen the negative impact on beneficiaries and providers, but the changes should go further. AHCA/NCAL recommendations include creating a uniform, electronic prior authorization form that all plans must use, among other recommendations.”

It submitted detailed charts that show plans’ current reluctance to use fully electronic transactions for prior authorizations and medical records submissions.

“The savings in time and cost that could be realized by providers and plans are significant. Additionally, prior authorizations are the most critical transactions impacting timely beneficiary access to care yet have the second lowest full electronic adoption,” AHCA noted in its letter, penned by Michael W. Cheek, senior vice president of reimbursement policy and market strategy.

AHCA estimated some $437 million in savings for the entire medical industry if full electronic authorization were adopted, noting that savings would be especially significant “In a post-acute care setting where prior authorizations require coordination between hospitals, skilled nursing facilities, and health plans.”

Medicare Advantage reduced access

AHCA also said it strongly supports a “prohibition on diverting patients to settings other than those recommended by the physician.” Cheek referenced a recent OIG report that found some post-acute care services are often inappropriately denied, disproportionately more than other covered benefits.

A former chief medical officer who commented anonymously told CMS it has become “nearly impossible for patients to go to acute inpatient rehab, long term acute care hospitals,” with authorizations taking 48 to 72 hours. Plans also are demanding early discharges from skilled nursing facilities. The writer, now a physician advisor at a major western health system, said such practices are “leading to increased readmission rates to the hospitals.”

Ronald Hirsch, MD, of Illinois, meanwhile, asked CMS to clarify how it would enforce its new proposals, particularly around ensuring access to and payment for covered services.

“For now, when an MA plan denies an inpatient admission, the provider, if contracted with the MA plan, can only pursue the internal contract appeal process with no avenue to address the CMS appeals process unless the patient themselves files an appeal,” he wrote. “Appealing directly with the MA plan will continue to be a futile activity, as providers have faced for 20 years and a formal process to appeal outside the contract provisions is necessary.”

But those who opt out of plans as a business decision – given frequent coverage denials and high-pressure, low-dollar plan pricing – may also be at risk of having their own reputations’ tarnished, AHCA warned.

“CMS proposes stricter beneficiary notification when a network change occurs. AHCA/NCAL is supportive of beneficiary education around which providers are in network and which are not. However, we caution that providers who voluntarily leave a health plan network not be portrayed as being terminated from the network,” Cheek wrote.