Medicare Advantage Issues Making Headlines

Medicare Advantage plans are being buffeted by bad news and regulatory challenges.

Last week produced a lot of Medicare Advantage (MA) news. Retired municipal workers of New York City are up in arms, as they are being forced to switch to a MA plan or pay an extra $191 a month to stay with traditional Medicare. Reports initially noted that many of these retirees who have been receiving care at prestigious places like Memorial Sloan Kettering (MSK) are now being told their care will not be covered, since that system is out-of-network. Other reports suggest that the retirees can see any medical provider that accepts Medicare, including MSK, as this MA plan was specially designed to allow payments to out-of-network providers at Medicare rates. The NYC teacher’s union has even established special web pages to try to sort out the confusion.

There was also word that Mayo Clinic will no longer see patients who are covered by a MA plan that is out-of-network, most notably UnitedHealthcare (UHC), which also happens to be based in Minnesota. Mayo Clinic is well-known for accepting patients from around the world for care, especially for patients with rare or difficult-to-treat illnesses, and the loss of access for these MA patients is unlikely to be readily accepted. And finally, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released another audit of an MA plan’s HCC coding that had a 73 percent error rate. The week was not kind to MA plans.

Hospices were also in the news last week, and not in a good way. An OIG report looked at 10 years of claims and found some disturbing numbers. They noted a very large increase in the number of for-profit facilities, but what seemed to concern the OIG the most was the increase in Part B spending on patients enrolled with for-profit hospices for Part b services and durable medical equipment (DME) that were carved out of the hospice benefit, because the services were reported as unrelated to the patient’s terminal illness. The OIG promised more audits to come.

As we have seen with many areas that are selected for audit, it is difficult to know which issue came first. In this case, were the nonprofit hospices less familiar with the billing rules for unrelated services and underused them, but now the for-profit hospices are billing correctly, making the pattern appear suspicious, or is there truly misuse? Data patterns cannot answer that question; charts must be reviewed.  

Finally, there was an interesting case posted on one of the user groups I follow. The case management director posted that “We are having challenges with one insurer, not UHC, that denies every inpatient stay if the patient is here for less than three midnights. Example: a patient [was] admitted for respiratory failure with hypoxia and placed on BiPAP. We discharged her on day three. Peer-to-peer [contact] attempted, but the payer medical director will not even discuss the case, citing their short-stay policy.”

Amazingly, that payer’s policy is online, and it states that “It is our policy that inpatient hospital stays on day three and beyond are medically necessary when supported by nationally recognized clinical decision support tools. The only exceptions are inpatient-only surgeries, patients admitted to an intensive care unit who met criteria for ICU admission, and patients whose length of stay was shorter because they died, were transferred, or left AMA, as long as they met inpatient criteria during their hospital stay.”

So, what happened here? Well, this hospital has a contract with this payer, and the contract holds them to the plan’s published policies. The hospital leadership signed the contract, so everyone has to abide by it. It doesn’t seem rational to have a patient in observation for three days, but as long as the patient is getting the necessary medical care, the issue really is about the payment.

It occurs way too frequently that such clauses get overlooked in contract negotiations, which often concentrate on payment rates, without realizing that the excellent negotiated rate may never get paid, since other clauses prohibit submitting such a claim.

Programming Note: Listen to Dr. Ronald Hirsch every Monday on Monitor Mondays as he makes his Monday rounds, sponsored by R1 RCM.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn

Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, and the National Association of Healthcare Revenue Integrity, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Frank Cohen shows you how to leverage the Comprehensive Error Rate Testing Program (CERT) to create your own internal coding and billing risk assessment plan, including granular identification of risk areas and prioritizing audit tasks and functions resulting in decreased claim submission errors, reduced risk of audit-related damages, and a smoother, more efficient reimbursement process from Medicare.

April 9, 2024
2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Explore the top-10 federal audit targets for 2024 in our webcast, “Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets,” featuring Certified Compliance Officer Michael G. Calahan, PA, MBA. Gain insights and best practices to proactively address risks, enhance compliance, and ensure financial well-being for your healthcare facility or practice. Join us for a comprehensive guide to successfully navigating the federal audit landscape.

February 22, 2024
Mastering Healthcare Refunds: Navigating Compliance with Confidence

Mastering Healthcare Refunds: Navigating Compliance with Confidence

Join healthcare attorney David Glaser, as he debunks refund myths, clarifies compliance essentials, and empowers healthcare professionals to safeguard facility finances. Uncover the secrets behind when to refund and why it matters. Don’t miss this crucial insight into strategic refund management.

February 29, 2024
2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

HIM coding expert, Kay Piper, RHIA, CDIP, CCS, reviews the guidance and updates coders and CDIs on important information in each of the AHA’s 2024 ICD-10-CM/PCS Quarterly Coding Clinics in easy-to-access on-demand webcasts, available shortly after each official publication.

April 15, 2024

Trending News

Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →

SPRING INTO SAVINGS! Get 21% OFF during our exclusive two-day sale starting 3/21/2024. Use SPRING24 at checkout to claim this offer. Click here to learn more →