HJBR Sep/Oct 2024

MEDICARE ADVANTAGE DENIALS 14 SEP / OCT 2024 I  HEALTHCARE JOURNAL OF BATON ROUGE  taxpayers.” 26 In a statement for this article, OIG said providers may email specific concerns to the agency at public.affairs@oig.hhs.gov . “Input from health care providers about managed care practices are regularly sent to relevant subject matter experts, including in our agency’s leadership, for their aware- ness and to inform our work,”wrote OIG. Last year, the federal government paid MA plans more than $454 billion to pro- vide high-quality care to more than 30 million people. 27 KFF reports that nearly 60% of Louisiana’s Medicare beneficiaries are enrolled in an MA plan this year. 27 Pro- viders have applauded the OIG for expos- ing dangerous care denials and for calling on MA corporate leaders to provide bet- ter value to patients and taxpayers. 28 “The Medicare Advantage plans aren’t going to change until their board of directors at the company understands as a matter of cor- porate policy that this isn’t the way to go,” said Carter. n REFERENCES 1 U.S. Dept. of Health and Human Services, Of- fice of Inspector General. “Medicare Advantage Appeal Outcomes and Audit Findings Raise Con- cerns About Service and Payment Denials.” Re- port OEI-09-16-00410, Sept. 25, 2018. https://oig. hhs.gov/oei/reports/oei-09-16-00410.asp 2 U.S. Dept. of Health and Human Services, Office of Inspector General. “Some Medicare Advantage Organization Denials of Prior Authorization Re- quests Raise Concerns About Beneficiary Access to Medically Necessary Care.” Report OEI-09-18- 00260, April 27, 2022. https://oig.hhs.gov/oei/ reports/OEI-09-18-00260.asp 3 Centers for Medicare and Medicaid Services. “2024 Medicare Advantage and Part D Final Rule (CMS-4201-F).” Fact Sheet, Medicare Part D, Infla- tion Reduction Act (April 5, 2023). https://www. cms.gov/newsroom/fact-sheets/2024-medicare- advantage-and-part-d-final-rule-cms-4201-f 4 Centers for Medicare and Medicaid Services. “Fact Sheet #1: Inpatient Rehabilitation Facil- ity Classification Requirements.” Fact sheet, Jan. 25, 2005. https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/Inpatient RehabFacPPS/downloads/fs1classreq.pdf 5 Louisiana Hospital Association. “Colleen’s Story: Appeal and Report Harmful Medicare Advantage Denials.” Facebook, March 14, 2024. https://www.facebook.com/LAHospitals/ videos/252495247935007 6 U.S. Dept. of Health and Human Services, Office of Inspector General. “Some Medicare Advan- tage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Ac- cess to Medically Necessary Care.” Report OEI- 09-18-00260. April 2022. https://oig.hhs.gov/ documents/evaluation/3150/OEI-09-18-00260- Complete%20Report.pdf 7 U.S. Dept. of Health and Human Services, Of- fice of Inspector General. “Medicare Advantage Appeal Outcomes and Audit Findings Raise Con- cerns About Service and Payment Denials.” Re- port OEI-09-16-00410, September 2018. https:// oig.hhs.gov/oei/reports/oei-09-16-00410.pdf 8 Meyers, D.J.; Mor, V.; Rahman, M. “Medicare Ad- vantage Enrollees More Likely To Enter Lower- Quality Nursing Homes Compared To Fee-For- Service Enrollees.” Health Affairs (Project Hope) 37, No. 1 (January 2018): 78-85. DOI: 10.1377/ hlthaff.2017.0714 9 American Medical Association, American Academy of Child and Adolescent Psychiatry, American Academy of Dermatology, et al. “Pri- or Authorization and Utilization Management Reform Principles.” Report, accessed August 2024. https://www.ama-assn.org/system/files/ principles-with-signatory-page-for-slsc.pdf 10 Biniek, J.F.; Sroczynski, N.; Neuman, T. “Use of Prior Authorization in Medicare Advantage Ex- ceeded 46 Million Requests in 2022.” Kaiser Fam- ily Foundation, Aug. 8, 2024. https://www.kff.org/ medicare/issue-brief/use-of-prior-authorization- in-medicare-advantage-exceeded-46-million- requests-in-2022 11 Centers for Medicare and Medicaid Services. “Frequently Asked Questions related to Cover- age Criteria and Utilization Management Re- quirements in CMS Final Rule (CMS-4201-F).” Memorandum to “All Medicare Advantage Orga- nizations and Medicare-Medicaid Plans,” Feb. 6, 2024. https://www.aha.org/system/files/media/ file/2024/02/faqs-related-to-coverage-criteria- and-utilization-management-requirements-in- cms-final-rule-cms-4201-f.pdf 12 DaVanzo, J.E.; El-Gamil, A.; Li, J.W.; et al. “As- sessment of Patient Outcomes of Rehavilitative Care Provided in Inpatient Rehavilitation Facilities (IRFs) and After Discharge.” Dobson DaVanzo & Associates, Report, July 10, 2014. https://amrpa. org/portals/0/dobson%20davanzo%20final%20 report%20-%20patient%20outcomes%20of%20 irf%20v_%20snf%20-%207_10_14%20redated. pdf 13 American Hospital Association. “Examining Health Care Denials and Delays in Medicare Ad- vantage.” Statement to Senate Subcommittee on Medicare Advantage Delays and Denials, May 17, 2023. https://www.aha.org/testimony/2023- 05-17-aha-statement-senate-subcommittee- medicare-advantage-delays-and-denials 14 Louisiana Hospital Association. “Stop Harm- ful Cancer Care Delays in MEdicare Advan- tage: Gerald Militello, MD.” Facebook, April 2, 2024. https://www.facebook.com/LAHospitals/ videos/1156382158614094 15 Sen. Roger, M. (R-KS). “S.4532 – Improving Se- niors’ Timely Access to Care Act of 2024.” Intro- duced June 13, 2024. https://www.congress.gov/ bill/118th-congress/senate-bill/4532/text 16 American Medical Rehabilitation Providers As- sociation. “AMRPA Comments on Request for In- formation on Medicare Advantage Data.” Letter to Chiquita Brooks-LaSure, Centers for Medicare and Medicaid Services. May 29, 2024. https:// amrpa.org/Portals/0/AMRPA%20Comments%20 on%20MA%20Data%20RFI%20May%202024_ Final.pdf 17 Alkire, M.J.; Saha, S.; Ingram, M. “Trend Alert: Pri- vate Payers Retain Profits by Refusing or Delay- ing Legitimate Medical Claims.” Premier, March 21, 2024. https://premierinc.com/newsroom/blog/ trend-alert-private-payers-retain-profits-by- refusing-or-delaying-legitimate-medical-claims 18 Office of Sen. Bill Cassidy. “Cassidy, Warren, Blackburn, Cortez Masto Call for Better Medi- care Advantage Data Collection, Reporting.” News release, Dec. 8, 2023. https://www.cassidy. senate.gov/newsroom/press-releases/cassidy- warren-blackburn-cortez-masto-call-for-better- medicare-advantage-data-collection-reporting/ 19 American Hospital Association. “AHA RFI Re- sponse to CMS on Medicare Advantage Data and Oversight.” Letter to Chiquita Brooks- LaSure, Centers for Medicare and Medicaid Services, May 29, 2024. https://www.aha.org/ lettercomment/2024-05-29-aha-rfi-response- cms-medicare-advantage-data-and-oversight 20 Biniek, J.F.; Freed, M.; Neuman, T. “Gaps in Medicare Advantage Data Remain Despite CMS Actions to Increase Transparency.” Kaiser Fam- ily Foundation, April 10, 2024. https://www.kff. org/medicare/issue-brief/gaps-in-medicare- advantage-data-remain-despite-cms-actions-to- increase-transparency/ 21 Pestaina, K.; Lo, J.; Wallace, R.; Long, M. “Final Prior Authorization Rules Look to Streamline the Process, but Issues Remain.” Kaiser Family Foun- dation, May 2, 2024. https://www.kff.org/private- insurance/issue-brief/final-prior-authorization- rules-look-to-streamline-the-process-but-issues- remain/ 22 Centers for Medicare and Medicaid Services. 42 CFR Parts 422, 431, 435, 438, 440, and 457; Of- fice of the Secretary 45 CFR Part 156. Final Rule. Federal Register 89, No. 27 (Feb. 8, 2024): 8758- 8988. https://www.govinfo.gov/content/pkg/FR- 2024-02-08/pdf/2024-00895.pdf 23 CodeofFederalRegulations.§422.137,“Medicare Advantage Utilization Management Committee.” Last amended Aug. 6, 2024. https://www.ecfr . gov/current/title-42/chapter-IV/subchapter-B/ part-422/subpart-C/section-422.137 24 American Hospital Association. “AHA Urges MedPAC to Examine Medicare Advantage Deni- als, Hospital Market Basket.” Letter to Michael Chernew, Medicare Payment Advisory Com- mission, Nov. 30, 2023. https://www.aha.org/ lettercomment/2023-11-30-aha-urges-medpac- examine-medicare-advantage-denials-hospital- market-basket 25 U.S. Department of Health and Human Servic- es, Office of Inspector General. “Medicare Advan- tage Organizations’ Use of Prior Authorization for Post-Acute Care.” Accessed August 2024. https://oig.hhs.gov/reports-and-publications/ workplan/summary/wp-summary-0000873.asp 26 Inspector General Grimm, C.A. “OIG’s Van- tage on Medicare Advantage.” Speech to RISE Conference in Colorado Springs, March 7, 2023. https://oig.hhs.gov/documents/speeches/1106/ IG-Grimm-RISE-transcript.pdf 27 Freed, M.; Biniek, J.F.; Damico, A.; Neuman, T. “Medicare Advantage in 2024 Enrollment Update and Key Trends.” Kaiser Family Foundation, Aug. 8, 2024. https://www.kff.org/medicare/issue- brief/medicare-advantage-in-2024-enrollment- update-and-key-trends 28 U.S. Department of Health and Human Ser- vices, Office of the Inspector General. “In- spector General Christi A. Grimm 2023 RISE National Conference Speech.” You- Tube video, April 14, 2023. https://youtu.be/ fDzAb-6aog8?si=KIuiXj23d2yr8eoP