It's About Time, CMS

Medicare Advantage (MA) plans, to which my own parents belong, tout themselves to be just as good - if not better - than traditional Medicare. They tout themselves to cover everything that traditional Medicare covers, along with other things that traditional Medicare does not cover, such as dental and other benefits. They tout themselves are offering comprehensive healthcare for Seniors at an affordable cost.

The way they achieve these purported results is, sometimes, quite obnoxious. There has been a lot of press, finally, about how MA plans do not act "just like traditional Medicare." Finally, there is more scrutiny on how these plans deny care that would have been covered by traditional Medicare. From my Appeals Desk, I see firsthand how they deny hospital admissions and even deny diagnosis codes so that they can pay out less money.

The public scrutiny has now reached the ears of Centers for Medicare and Medicaid Services (CMS). In response, they have proposed changes to the rules that govern MA advantage plans. Among the many changes are these:

we propose that MA plans must comply with national coverage determinations (NCD), local coverage determinations (LCD), and general coverage and benefit conditions included in Traditional Medicare statutes and regulations as interpreted by CMS. Further, we propose that MA plans cannot deny coverage of a Medicare covered item or service based on internal, proprietary, or external clinical criteria not found in Traditional Medicare coverage policies.?

This means that, finally, MA plans must follow the Two Midnight Rule with respect to hospital admissions and inpatient status, and that MA plans cannot use commercial criteria - such as Milliman or Interqual - to deny hospital admissions at the inpatient level of care. For those who do not know, the Two Midnight Rule (simply) states that if a patient - as determined by their doctor - needs "medically necessary hospital level services" for more than two midnights, it qualifies at the inpatient level of care.

It's about time, CMS!

If MA plans are "just like traditional Medicare," then they should act "just like traditional Medicare." With these denial tactics, they hardly acted like "traditional Medicare." This will finally change with these new rules, and I - for one - am very happy with these changes.

Finally, there will be no more hospital stays - sometimes spanning days at a time - that are denied at the inpatient level of care that would have qualified under traditional Medicare. Finally, we will not have to memorize MCG or Interqual line by line to fight inpatient denials, only to be told, "Well, those are just guidelines." Finally, MA plans will start to look more like Medicare, and if - with these changes - the plans still are better than traditional Medicare, then the insurance companies will have nothing to worry about with respect to losing Medicare beneficiaries.

It's about time, CMS. It's about time.