Hospitals say Medicare plans ignoring new curbs on coverage denials
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Leading hospital trade groups accused Medicare Advantage giant UnitedHealthcare and others of flouting new federal rules meant to crack down on insurers' restrictions on medically necessary care.
Why it matters: Their complaints could serve as an early test of how the Biden administration will enforce the new requirements.
Catch up quick: Earlier this year, the Centers for Medicare and Medicaid Services finalized a rule barring Medicare Advantage plans from adding restrictions to basic coverage that the traditional program provides.
- The rule followed a 2022 report from Health and Human Services investigators that found MA insurers sometimes delayed or denied medically necessary care that would be covered by traditional Medicare.
- "Our goal to ensure that MA enrollees receive the same items and services as beneficiaries in the [traditional] program is accomplished when the same coverage policies and approaches are used," CMS wrote in the final rule.
- The rule allows MA plans to adopt their own coverage criteria when necessary to "consistently" determine medical necessity.
State of play: The American Hospital Association in a Monday letter to CMS alleged that UnitedHealthcare, the nation's largest MA plan, and others are still using restrictive criteria to evaluate whether they will cover care.
- The AHA called on CMS to clarify the new rules, which apply to 2024 coverage, and take action against noncompliant insurers, "including applying intermediate sanctions where appropriate."
- The Federation of American Hospitals in a separate statement accused United of an "unlawful" coverage policy.
Zoom in: The AHA notes that a United document summarizing its coverage policies says the insurer uses InterQual, a clinical decision support tool that assists with health care utilization management.
- Utilization management includes measures like prior authorization, in which a doctor must get an insurer's OK to provide a treatment, or step therapy, in which patients must try a cheaper drug before moving onto a more expensive one.
- The United document says it uses InterQual in coordination with providers' medical judgment to support medical necessity decisions.
- CMS rules explicitly prohibit MA plans from using InterQual "to change coverage or payment criteria already established under Traditional Medicare laws."
- A CMS spokesperson said the agency received the letter and will respond to AHA.
The other side: United's coverage summary says it uses internal criteria "in order to ensure consistency in reviewing the complex medical factors" that a physician uses to decide whether to admit a patient into the hospital.
- A United spokesperson said the AHA "is advocating a position that is inconsistent with language in the CMS Final Rule for 2024. Our Medicare Advantage Hospital, Emergency, and Ambulance Services Coverage Policy complies with CMS' Final Rule."
