Satisfaction Guaranteed: Turn Frustration into Action with Medicare’s Complaint ProcessRichelle Marting JD, MHSA,RHIA,CPC,CEMC,CPMA Have you ever encountered a situation where a Medicare Advantage plan refused to authorize a test or service your patient needed, and you knew the services should be covered, but your best efforts during peer to peer were to no avail and you receive that dreaded fax saying “DENIED”? Have you ever wished there was someone, anyone, to whom you could report examples of egregious Medicare Advantage plan denials that truly compromise your patients’ health? What if I told you there is a way to report these issues to the very agency that oversees the Medicare Advantage program? That’s right – CMS has developed an enhanced pathway for providers and hospitals to file complaints against Medicare Advantage plans. And even better, the new pathway enters your complaint into a system called the Complaint Tracking Module – a program shared between CMS and Medicare Advantage plans for the exchange of information surrounding complaints. When a complaint is entered into the Complaint Tracking Module (CTM), it is assigned a case number. That case number becomes your very own unique complaint against the plan. The significance of this complaint tracking system is that CTM case numbers are an important metric to Medicare Advantage plans. They contribute to one of the components of the plans’ Star Ratings: the Complaints Against the Plan metric. A quick Google search will reveal how important Star Ratings are for Medicare Advantage plans. One MA plan sued CMS for the plan’s 2025 Star Ratings, saying “the lawsuit is an attempt to reverse the decision which has already hurt its stock value and threatens a loss of billions of dollars in incoming revenue.” Numerous others have followed suit, citing similar financial repercussions. How to Use the Complaint Process CMS has issued a number of complaint form versions over the last several months and is currently using version 7. Right now, these forms are not publicly posted by CMS but you soon be able to them at www.acpadvisors.org under Resources. For now, Dr. Hirsch, ACPA Update editor, has posted them to his webpage https://www.ronaldhirsch.com/filing-ma-2-mn-rule-violation-complaints.html. You can also obtain a copy by emailing [email protected]. There are nine data areas to complete on the form: date of submission; entity submitting complaint; submitter’s name, email address and phone number; patient name; patient’s claim number, Medicare beneficiary number, or alternatively date of birth; provider’s name, phone number and email address; name of the MA organization; claim number; and date of service. But don’t forget to include one of the most important, yet unsolicited items: the substance of your complaint. Many of these fields can be prepopulated for recurrent use (e.g. name, address, and phone number of the hospital). You can even pre-populate the nature of your complaint for certain common issues such as an MA plan failing to comply with the two-midnight benchmark. An example of the substance of your complaint may look something like this: The plan made an adverse organization coverage determination for its MA plan member, denying authorization for inpatient hospital services in a manner that is more restrictive than, and inconsistent with, 42 CFR 412.3. “In regards to inpatient admissions at 412.3, we confirm that the criteria listed at 412.3(a)-(d) apply to MA.” 88 Fed. Reg. 22191 April 12, 2023. The inpatient admission criteria at 412.3 are based on the expectation of the admitting physician at the time the decision to admit the patient is made. “An MA organization may evaluate whether the admitting physician’s expectation that the patient would require hospital care that crosses two-midnights was reasonable”, but “that evaluation should defer to the judgment of the physician as long as that judgment was reasonable”. CMS Memo to all Medicare Advantage Organizations February 6, 2024 p. 9.The inpatient criteria at 42 CFR 412.3 are fully established coverage criteria under Traditional Medicare, and “MA plans may not use InterQual or MCG criteria, or similar products, to change coverage or payment criteria already established under Traditional Medicare laws.” 88 Fed. Reg. 22194 April 12, 2023. If the plan’s evaluation reflects the admitting physician’s expectation that the patient would require two midnights of hospital was unreasonable, the final decision must be made by a physician or other professional with expertise in the services at issue. 88 Fed. Reg. 22195 April 12, 2023; 42 CFR 422.566(d). The plan did not comply with these regulatory requirements:
You can complete the form in .pdf, but it must be password protected. If you don’t have the right license for Adobe or other .pdf reader’s password protection feature, you can also screenshot the form and put it into a Word document as an image. Prepopulate all your repetitive data and save as a template. Word documents can be easily password protected, and CMS will accept the document in Word format. Next, submit the complaint form to CMS [email protected]. You can create brief email message to use for every complaint form. For example, mine says “The password for the attached provider complaint is the passcode within the Version 7 complaint form instructions.” What to Expect You should expect a response within about 2-3 business days with your CTM case number. Once issued a CTM case number, you should be contacted by the plan. This is almost always by an unscheduled phone call. Some plans will merely prepare a written response to the complainant within about 30 days of the complaint being filed. Sometimes, you get a favorable decision where the plan overturns its decision. You can communicate these decisions to the revenue cycle team to ensure payment is appropriately received. You may not get overturns on every complaint filed. But you will get some. For those not overturned, you will still be recording a complaint against the plan and its Star Rating. And for that opportunity to have your voice heard on an egregious denial, by the very agency with the opportunity to promote MA plan compliance, while etching a small ding against their Star Ratings? Priceless. Satisfaction guaranteed. Mrs. Marting is owner of Marting Law, LLC and Director of Managed Care Contracting at North Kansas City Hospital |