BALTIMORE — Providers must play an active role in stopping aggressive Medicare Advantage practices that have for years limited access to skilled nursing care, a top managed care expert warned administrators gathered for a national conference here Wednesday.

The Centers for Medicare & Medicaid Services in early April finalized a new rule that seeks to rein in widespread use of pre-authorization requests and service denials by Medicare Advantage plans. In a call with stakeholders Tuesday, CMS Administrator Chiquita Brooks-LaSure called the rule a key element of agency efforts to ensure beneficiaries receive “timely access to medicare care.”

But Maureen McCarthy, president and CEO of Celtic Consulting, warned that providers will have to educate themselves on the Medicare Advantage rule and stand up to insurers who may try to keep using underhanded tactics. 

Traditionally, the top two services denied by MA plans have been MRIs and nursing home stays, McCarthy said during a session at the American College of Health Care Administrators’ 2023 Convocation. Though the new rule requires insurers to cover all services available under traditional Medicare, McCarthy worries that they will continue to try to circumvent paying for SNF stays that beneficiaries have a right to.

“I think we’re going to have to fight for it,” she said. “We’re on their hit list. I think they’re going to go kicking and screaming at these changes.”

Starting June 5, practices around coverage and length of stay are required to comply with national coverage determinations, local coverage determinations, and the coverage and benefit conditions of traditional Medicare.

That means Insurers should no longer be able to reject payment based on their own medical determinations. Now, medical necessity and other clinical decisions will be dictated by the patient’s provider — a nursing home’s rounding physician or medical director — rather than a plan’s case management team. Also, pre-authorizations will be allowed only when a diagnosis is unclear, which should make for easier transfers of hospital patients.

That should lead to cleaner practices among some insurers, McCarthy said. For those who don’t play within the new regulations, she expects nursing homes to submit more appeals and win them.

McCarthy said providers may even be able to use the rule to better negotiate with Medicaid managed care providers in some states, though the rule dictates only plan behavior at the federal level.

“If nothing else, there are some bumpers around this now that are going to be helpful,” McCarthy said.

Doug Jacobs, MD, chief transformation Officer in the Center for Medicare, said on Tuesday’s stakeholder call that the agency would watch what happens after the rule’s effective date and continue to refine the Medicare Advantage program, which now serves more than 48% of all Medicare beneficiaries.

“The next step is how these provisions get implemented on the ground,” he said. “It will be important for us to hear how it’s going and what we are learning.”

McCarthy said that’s a message providers should take to heart in conversations with their CMS regional offices.

“I don’t know the answer as to when CMS will be our police and fight for us, but in the meantime, we can’t wait for that because Medicare Advantage will not be forthcoming and tell us, ‘By the way, the rules changed,’” McCarty said. “It’s going to be business as usual for them unless you come back and fight for yourself and tell them, ‘You can’t do this anymore.’ Here’s what to say: ‘I’ll report you to CMS.’ That is the one, most valuable sentence you can add when dealing with managed care.”