Response to RFI for 2017 MAO Transformation Ideas
Thomas E. Price, M.D.
Secretary of Health and Human Services
Hubert H. Humphrey Building
200 Independence Avenue, S.W.
Washington, D.C. 20201
April 24, 2017
Dear Secretary Price and CMS Administrator Verma:
The American College of Physician Advisors (ACPA) appreciates the opportunity to respond to your RFI soliciting ideas to better achieve transparency, flexibility, program simplification, and innovation in the administration of Medicare Part C. The majority of ACPA members are physicians who are professionals with specialization in quality, utilization review, and utilization management for hospital-based providers. Our members interact with Medicare Advantage Organizations (MAOs) on a daily basis, thus gaining detailed 360-degree knowledge and experience from the point of care. We hope that the ACPA recommendations offered here will be useful to help achieve greater standardization, transparency, and effectiveness in the Part C program for the benefit of all stakeholders.
Medicare Part C offers several potential advantages to Medicare beneficiaries and to the Centers for Medicare and Medicaid Services (CMS.) MAOs are already required to provide all of the benefits of traditional Medicare. Among the potential advantages to beneficiaries are receiving benefits which would not otherwise be covered by traditional Medicare, such as vision and dental benefits, prescription drug coverage, and wellness programs. The principle benefit to CMS is fixed program cost, as the third party assumes both financial risk and administrative claims responsibilities.
Our members have repetitively insisted that stronger oversight of MAOs is needed as the current process has led to increasingly wasteful amounts of plan-related administrative burden imposed on hospitals in order for them to be fairly reimbursed for the care they provide. This has resulted in many clinical support personnel spending the majority of their productive time meeting these individual MA Plan-specific rules, rather than focusing on the many complex issues surrounding beneficiary care.
We strongly believe that the regulations in 42 CFR §422 and the Medicare Managed Care Manual can be strengthened to provide greater standardization, clarity, and transparency on the operations, obligations, and responsibilities of the MA Plans in order to prevent “cherry picking” or selective enforcement of Medicare rules by the MA Plans to their own benefit. Both contracted and non-contracted providers are experiencing these issues, but contracted providers are affected to a much greater extent due, in part, to the lack of CMS-granted appeal rights. Contracted providers are under increasing pressure to become non-participating with MAOs as non-contract providers receive non-discounted traditional Medicare payments and have standard Medicare appeal rights.
These issues affect the majority of hospital providers so clear regulatory intervention and strong policy guidance from CMS are needed. CMS should monitor for beneficiary safety and access as providers withdrawing from MA Plans could threaten MAO network adequacy and beneficiary choice.
The following examples provided by our membership reflect what we have experienced as a result of national practices of at least one of the four major MAOs.
- Selective enforcement of Two-Midnight (2-MN) Rule policies that are beneficial to MAOs, such as level of care interpretations that lead to significantly fewer inpatient admissions and more prolonged observation stays than the 2-MN Rule would require.
- Inordinate delay in approval of sub-acute rehabilitation:
- Prolongs patient recovery time as the beneficiary’s primary need is for rehabilitation optimally provided in a rehab setting and not within an acute care hospital.
- Prolongation of beneficiary hospitalization also forces hospitals to absorb the cost of care that should be provided at a lower level.
- Nearly universal refusal to approve acute inpatient rehab.
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