Ever More Watching and Waiting on Federal Healthcare Moves

It’s two weeks into November, and still no Outpatient Prospective Payment System (OPPS) Final Rule from the Centers for Medicare & Medicaid Services (CMS).

Now, will the implementation date be pushed back, since federal law mandates a 60-day period between publication in the Federal Register and the rule going into effect? Who knows what will happen.

But as we wait, there is other news.

First, Aetna has delayed the start date for their very unpopular and very immoral (yet sadly legal) plan to pay inpatient admissions that do not meet MCG inpatient criteria at a lower, observation-like rate. They pushed back the start date to Jan. 1 and will not apply MCG criteria to inpatient admissions of five or more days, instead paying them at the contracted inpatient rate.

But this does not mean your finance team should not continue to push back on this. You know the other payors are watching Aetna’s actions and likely running the numbers, deciding if and when to adopt this as their payment policy.

Next, CMS named the companies that got the contracts to participate in the Wasteful and Inappropriate Service Reduction (WISeR) prior authorization demonstration project. There are six companies, and I will admit there is only one whose name is vaguely familiar to me, even though the websites of all six indicate they work in healthcare using artificial intelligence (AI).

But the program proceeding is not a sure thing, as on Friday, six members of the House of Representatives introduced a bill to prohibit CMS from implementing WISeR or any similar program. I doubt this bill will be getting a vote anytime soon, so affected providers should plan for Jan. 1. Yet even with contractors named, so far not one of the companies has any information on their website about how requests should be submitted. More watching and waiting.

I can also report that there is not yet any sign of the new Important Message from Medicare (IMM) or Medicare Outpatient Observation Notice (MOON) to replace the versions that are expiring very soon. I have sent requests for updates, but there is silence from CMS. I sent another email to CMS on an unrelated issue, and the automatic response was “we will respond as soon as possible once communications are permitted.”

Is CMS leadership actually preventing staff from communicating with providers? That’s really sad, if true. As there is talk of a settlement in the shutdown, we can only hope that release of these new forms is on the “to-do immediately” list, along with release of the OPPS Rule.

I will note that in the past, when forms expired, they allowed the use of the expired form until the new forms were released, and then there was a grace period. I have also seen the proposed changes to the MOON, and while the content is similar, the design is markedly different.

Finally, some of you may know that Maximus, the contractor that acts as the Qualified Independent Contractor (QIC) for Medicare, reviewing second-level appeals for Medicare Advantage (MA), has published their latest findings. And their data from 2025 is rather depressing.

For denied inpatient admissions, they approved 10 percent. For patients appealing to get access to inpatient rehabilitation, they approved 1 percent, and for Long-Term Acute-Care Hospitals LTACHs, they only approved two of the 2,680 appeals filed.

But there is always a bright spot. And here it was a reversal of a Diagnosis-Related Group (DRG) downgrade of sepsis, wherein the MA plan claimed they downgraded the DRG of sepsis to urinary tract infection (UTI), as the documentation did not support the diagnosis of sepsis, but at the same time they told Maximus that they did not have any medical records to forward to them, and that they never even requested the records from the provider. Maximus gave them an earful for playing those games. Sadly, they did not name the MA plan, perhaps to spare them the ridicule you know they would get from me.

The lesson here is that if you are getting DRG downgrades, your first check should be to ensure that the payer actually requested the medical records. If they are removing diagnoses as invalid without even reviewing records, their behavior needs to be called out, preferably publicly, and to your state insurance commission.