A final rule announced by the Centers for Medicare & Medicaid Services Thursday revised the appeals process for Medicare Advantage beneficiaries who have been denied coverage. The new rule should be a significant help for both beneficiaries and long-term care providers, sector leaders said Friday.
The changes are in line with the rule proposed in November and would bring MA appeals more into line with traditional Medicare.
Beneficiaries denied MA coverage will no longer be required to shoulder the cost of their treatment if they do not appeal quickly enough and their appeal is unsuccessful. That old status quo has been a significant barrier to appeals, according to Nicole Fallon, vice president of integrated services and managed care at LeadingAge.
“MA plan enrollees whose appeal is unsuccessful must [currently] pay privately for any services received after the date the plan terminated services,” Fallon explained Friday. “Therefore, enrollees are often reluctant to appeal due to the financial consequences.”
While MA denial of coverage appeals have a high success rate — more than 80% — only 11% of denials were being appealed previously. More than half of Medicare beneficiaries now use MA plans.
Independent review
Crucially, the final CMS rule makes fast-track appeals subject to independent reviews by a Quality Improvement Organization rather than by the MA plans themselves. It also removes a former provision requiring beneficiaries to forfeit their right to an appeal when they leave a facility.
Those changes should be a huge help for providers “stuck in the middle” of beneficiaries upset at losing their coverage and MA plans that are denying them funding, according to Maureen McCarthy, president and CEO of Celtic Consulting.
“I’m hoping this can really level the playing field for providers,” she told McKnight’s Long-Term Care News Friday. “[The new process] should be helpful to providers so that they can get in and have an independent review of denied care … rather than going back to the insurance company. Because if they’re not following the rules in the first place when it comes to coverage, what makes you think they’re going to overturn that?”
Providers have seen themselves as victims as average MA saturation cleared 51% for the first time last year, with it surely en route to even higher levels. The plans have winched down average lengths of stay while, in many cases, also tightening payouts and prior authorizations.
McCarthy said that the ability to escalate appeals to an administrative law judge will be vital for providers and beneficiaries looking to reinstate coverage moving forward — especially in cases of post-payment denials when care has already been delivered before payment is denied. Where there had previously been “no recourse” for providers looking at a minimum of heavily delayed payments, there is now a much higher chance for reinstatement if providers can make their case well.
“You need an independent review,” McCarthy said, “and I think that’s where providers are going to have the best outcome — when they get to the administrative law judge level and they’re able to show the judge the actual regulation that governs that area.”
