The Centers for Medicare & Medicaid Services (CMS) released the 2024 Oversight Activities HPMS memo on October 24 which stated their Account Managers will begin having strategic conversations in November with Medicare Advantage Organizations (MAOs) to validate that plans understand and have implemented the new utilization management (UM) rules that are effective January 1, 2024. What prompted CMS to update the regulations?
In September 2018 the Office of Inspector General (OIG) published Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials in which they stated that “high numbers of overturned denials upon appeal, and persistent performance problems identified by CMS audits, raise concerns that some beneficiaries and providers may not be getting services and payment that MAOs are required to provide.” At that time, OIG made three recommendations to the Center for Medicare & Medicaid Services (CMS) “(1) enhance its oversight of MAO contracts, including those with extremely high overturn rates and/or low appeal rates, and take corrective action as appropriate; (2) address persistent problems related to inappropriate denials and insufficient denial letters in Medicare Advantage; and (3) provide beneficiaries with clear, easily accessible information about serious violations by MAOs.”
Key Takeaway
MAOs denied prior authorization and payment requests that met Medicare coverage rules by:
- Using MAO clinical criteria that are not contained in Medicare coverage rules.
- Requesting unnecessary documentation.
- Making manual review errors and system errors.
Four years later, the OIG had similar findings in their April 2022 report Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care in which they clearly identified their concerns and the areas in which plans should improve their processes. It suggested CMS take the following actions:
- Issue new guidance on the appropriate use of MAO clinical criteria in medical necessity reviews.
- Update its audit protocols to address the issues identified in this report, such as MAO use of clinical criteria and/or examining particular service types.
- Direct MAOs to take additional steps to identify and address vulnerabilities that can lead to manual review errors and system errors.
The evidence of continuing challenges prompted CMS to incorporate the OIG suggestions into the Medicare Program; Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly and to intensify their oversight of how plans deliver benefits to members and guarantee beneficiaries receive appropriate care when and where needed.
What should you expect from a strategic conversation with your plan’s CMS Account Manager?
Prep for the Strategic Conversation
Know what changed and the impact to your organization. Be prepared to provide:
- Updated policies and procedures
- Staff training materials and attestations of completed training
- Staff monitoring, oversight, and feedback to prevent, detect, and correct potential manual and system errors.
- Provider training and communications reflecting updated authorization requirements and processes
- Documentation of any necessary system updates
- Results from internal oversight/audits validating compliance
- Internal corrective action plans implemented
Julie Mason, President at Integritas Medicare did a great job in her article New Medicare Advantage UM audits are coming...are you ready? describing the how to identify gaps in your utilization management (UM) processes in preparation for being audited.
Simply preparing for an audit isn’t sufficient. CMS requires plans to establish sustainable operational processes that are both efficient and compliant, guaranteeing timely access to care for all members. To accomplish this, it’s crucial to take intentional steps, establish clear expectations, utilize data, and secure leadership support. Adapting to change can be difficult, but embedding compliance and understanding within your team’s culture can be helpful. Encourage an environment in which asking questions and seeking understanding are the standard, and equip your team with the essential knowledge, training, and information to empower them and foster their professional development.
Healthmine has a team of subject matter experts with extensive operational and compliance expertise, ready to assist you in navigating these changes. We can provide real-time coaching, education, support, and training to help hardwire best practice workflows, activities, and interventions into your routine operations and infrastructure for continuous, sustainable success. For more information, please contact me at Cherie.Shortridge@healthmine.com.