Reforming Medicare Advantage: Changes Could Be on the Horizon

Reforming Medicare Advantage: Changes Could Be on the Horizon

In Washington, D.C., the buzz is palpable as the Biden administration gears up to propose significant reforms to the Medicare Advantage (MA) program. With only a few months left in power, the administration is pushing hard to make changes that could improve health care for millions of seniors. However, they will need support from the Trump administration to help get these proposals across the finish line.

Growth of Medicare Advantage

As it stands now, the Medicare Advantage program has become quite popular, covering over half of the seniors enrolled in Medicare. However, it has come under fire recently for concerns regarding coverage quality and access. These worries have intensified, particularly after reports highlighted some troubling trends relating to how claims are managed. For instance, a staggering 80% of claims denials are overturned upon appeal, yet fewer than 4% of those denied claims actually get appealed in the first place, according to the latest data from the Centers for Medicare & Medicaid Services (CMS).

Dr. Meena Seshamani, the Medicare Director, shed some light on the impact of these denials during a press call. She noted that “more patients could likely have access to care if inappropriate prior authorization did not block it.” Past research supports this statement; a 2018 audit revealed that MA plans ultimately approved around 75% of previously denied requests after an appeal.

Key Changes Proposed

The newly proposed rules aim to tackle these problems head-on. To start, the proposal would put limitations on overly restrictive utilization management policies and clarify the payment rules for MA plans. Plans will now need to comply with both national and local coverage determinations, as well as general rules seen in traditional Medicare regulations, starting this year. In cases where there isn’t a predetermined Medicare coverage decision, MA plans can develop their own internal coverage criteria, following annual reviews by a clinical committee.

To ensure transparency, the new rule mandates that these internal coverage policies be made public and readily available on plan websites. Additionally, MA plans will have to keep members informed about their right to appeal denied claims. Moreover, the proposal aims to prevent MA plans from revisiting already approved authorizations for inpatient hospital admissions, enhancing patient trust in the system.

Harnessing Technology Responsibly

On the tech front, the proposed regulations also touch on the use of artificial intelligence (AI). Plans will be required to make sure services provided to their beneficiaries are equitable, regardless of whether the services are delivered by humans or automated systems. Discrimination based on a member’s health status will not be tolerated, making it clear that all enrollees deserve fair access to healthcare.

Addressing Conflicts of Interest

Another important aspect of the proposed changes seeks to address the issue of vertical integration, where large insurers also operate healthcare providers. This setup can lead to potential conflicts of interest, with insurers steering members toward their own networks. The CMS is particularly focused on UnitedHealth in this context as the Department of Justice investigates its dual operations.

Improving Patient Communication

In an effort to better inform seniors about the choices available to them, the proposed rule also strengthens the oversight of marketing practices for MA plans. Over 1,500 misleading television ads were denied just this year! The aim is to ensure that seniors receive accurate information and can compare options efficiently, including any potential eligibility for subsidies in traditional Medicare.

The CMS is also planning to improve how beneficiaries can access provider directories, which will now be required to be up-to-date and accessible via the government’s Medicare Plan Finder. This enhancement will help tackle the issue of ‘ghost networks’, ultimately leading to clearer information about available healthcare providers.

Conclusion: A Positive Move Forward

All these proposed tweaks could have a profound impact on both patients and the healthcare system as a whole. By focusing on transparency, eliminating unnecessary roadblocks, and ensuring equitable access to services, the proposed reforms could play a significant role in improving patient care. As the Biden administration continues to push forward, many are optimistic about these changes and hope they can lead to a healthier future for America’s seniors.