AHA critiques Medicare Advantage, makes recommendations regarding sepsis criteria, SDOH, and medical necessity determinations

By Brian Murphy

The American Hospital Association’s commentary to CMS on the Medicare Advantage (MA) program CY 2024 proposed rule is a good read … if you are a CDI and coding policy wonk who likes this sort of thing.

As I do. Because it offers a candid look into who wields the ultimate power of medical decision-making.

The AHA’s main call to action is, unsurprisingly, for CMS to strengthen its consumer protections and oversight of MAOs. Secondarily, the AHA supports CMS’ “commitment to advancing health equity and improving access to behavioral health services, and thus support the proposals designed to better address social determinants of health (SDOH).”

There has been much talk about SDOH and I’m confident it will be only a matter of time before social circumstances like unsheltered homelessness (Z59.02) and problems related to living alone (Z60.2), have real payment ramifications for hospitals. CDI/coding professionals should be coding SDOH anyway, because they can be captured from any clinician documentation and the associated burden is low. Moreover, these conditions can impact payment by factoring into professional E/M billing (see ICD-10 Monitor article below).

Then things get interesting. The AHA launches into a critique of MA’s well-documented history of denying medically necessary services typically covered under Medicare. The AHA calls for a greater alignment between traditional Medicare and the MA program, which on its face seems logical—why should treatment differ based on the insurer?

Under the proposed rule, MA programs could only create internal medical necessity criteria “when there is no applicable coverage criteria in Medicare statute, regulation, NCD [national coverage determination], or LCD [local coverage determination].”

If made final, this would represent a huge wresting back of power; to those who raise the specter of “death panels” when the issue of national health insurance is raised, surely the removal of proprietary, black-box denials of coverage by MA organizations is a step in the right direction. We all want transparency.

There are some great clinical examples of unwarranted downgrades from IP to observation on p. 24 of the report which underline the need for transparency of coverage.

Who doesn’t like sepsis talk? The AHA relays the struggle between the use of sepsis-2 vs. sepsis-3 criteria and recommends that CMS “enhance regulatory language to specifically address sepsis, explicitly directing plans to comply with Medicare criteria and coverage rules for sepsis related services — and prohibiting the use of all internal MAO criteria.”

Will CMS get into the game of adopting diagnostic criteria rather than its typical stance of deferring to medical societies? Its hands-off approach is getting harder to justify as CMS continues to push on paying for quality, which begs the question of what quality care is.

How to enforce? The AHA calls on CMS to “regularly audit a sample of MAO denials, using a similar methodology as the 2022 HHS-OIG report, to review MAO determinations for the appropriate application of Medicare coverage rules and criteria.”

The final rule expected to be published by April 3.

To sum up, interesting times in this struggle of big power-players: Public vs. private insurance, and independent physician clinical decision-making vs. coverage and payment realities.

Relevant links below:

AHA comments: https://www.aha.org/system/files/media/file/2023/02/aha-comments-on-the-cms-proposed-rule-for-policy-and-technical-changes-to-the-medicare-advantage-program-in-cy-2024-letter-2-13-23.pdf

ICD-10 Monitor article on SDOH: https://icd10monitor.medlearn.com/sdoh-at-the-intersection-of-lifestyle-and-patient-care/

Proposed rule: https://www.federalregister.gov/documents/2022/12/27/2022-26956/medicare-program-contract-year-2024-policy-and-technical-changes-to-the-medicare-advantage-program

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