HJBR Sep/Oct 2024

HEALTHCARE JOURNAL OF BATON ROUGE I  SEP / OCT 2024 13 efforts to increase transparency of the coverage criteria, such as those recently included in a final rule, may be more likely to have an impact.” KFF has also pointed to a lack of transparency related to deci- sions from the independent review entity that considers appeals after an MA physi- cian denies a request. 21 CMS opted against requiring plan-level data in 2026, saying it did not want to over- whelm consumers and that it wanted to “limit plan burden.” 22 The agency will con- sider more detailed reporting requirements during future rulemaking. INTERNAL MA PLAN MONITORING CMS now requires all MAplans to estab- lish a utilization management committee to review prior authorization policies annu- ally and ensure compliance with traditional Medicare’s national and local coverage guidelines. 23 The AHA urged the Medicare Payment Advisory Commission to monitor whether these committees will have author- ity to overturn harmful policies, writing that “many providers fear that these committees will serve as little more than a rubber stamp for plan policies.” 24 During the public comment period on the 2024 MA final rule, health insurance com- panies argued that forcing them to follow traditional Medicare’s clinical criteria would lead to “fewer affordable, high-quality plan choices for beneficiaries” and “adverse health impacts.” “CMS in the rule does give MAplans cer- tain limited sets of circumstances where they can use their own internal coverage criteria when traditional Medicare criteria is not fully established,” said Michelle Miller- ick, AHA director for health insurance cov- erage and policy. “Some MAplans are over- extending that limited flexibility, and there’s not necessarily a clear definition of exactly when Medicare criteria is fully established, especially for level of care determinations. Stronger enforcement of these provisions from the 2024 MA final rule is needed to ensure plans do not continue to use more restrictive criteria than Medicare.” DENIAL LETTER LANGUAGE Beginning in 2026, CMS said the prior authorization denial letters must be “suf- ficiently specific to enable a provider to understand why a prior authorization has been denied and what actions must be taken to resubmit or appeal.”The agency said the MAplans’ reason for denial “could include” a variety of explanations, such as “how doc- umentation did not support a plan of care for the therapy or service” or “specifically, why the service is not deemed necessary.” Experts say they are cautiously optimistic, but that it remains to be seen how effectively CMS will enforce this policy for patients like Carrigan and Sercovich. TARGETED AUDITING/ AGGRESSIVE ENFORCEMENT This year, CMS said it will conduct rou- tine and focused audits to assess compli- ance with the 2024 MA rule. In a statement, the agency said that it “may issue compli- ance and enforcement actions, including civil monetary penalties to MA organiza- tions who fail to comply with our regula- tions.”Providers may send complaints with specific examples of MAplans’noncompli- ance to part_c_part_d_audit@cms.hhs.gov . The OIG recently announced plans to audit MA IRF denials and will issue a report in 2026. 25 “I can tell you with great certainty that you will see us expanding our over- sight of Medicare Advantage in the com- ing months and years,” said HHS Inspector General Christi A. Grimm during a recent speech to MA company leaders. “We want MedicareAdvantage to be successful. OIG’s work helps ensure that the program works as intended for Medicare enrollees and for APPROVED APPEAL X X X DENIED X X X DENIED X X X DENIED X X X DENIED X X X DENIED X X X DENIED X X X DENIED X X X DENIED X X X DENIED “According to KFF, MA plans denied 3.4 million prior authorization requests in 2022. Only 1 IN 10 DENIALS were appealed, but MORE THAN 8 OUT OF 10 APPEALS resulted in overturning the denial.”