Holding Medicare Advantage Plans Accountable: A Hospital’s Crucial Role in the 2024 Rule

The Centers for Medicare & Medicaid Services (CMS) has finally taken a step towards holding Medicare Advantage (MA) plans accountable for their questionable practices with the recent finalization of the CY 2024 Medicare Advantage Rule.

Lori Intravichit, CEO of Sunlit Cove Healthcare, said:

This rule brings much-needed clarity and stricter guidelines to the healthcare landscape, but its effectiveness hinges on a critical factor: Hospital Revenue Cycle monitoring.

The Rule: A Step in the Right Direction

The new rule addresses several key concerns surrounding MA plans, including:

  • Denying coverage based on internal criteria: MA plans can no longer restrict or deny coverage for services covered by traditional Medicare based on their own internal rules. This ensures patients receive the care they need, regardless of which plan they’re enrolled in.
  • Two-Midnight Rule: This rule clarifies when an inpatient admission is justified, ensuring patients don’t face coverage denials for short hospital stays.
  • Expert review for prior authorizations: Prior authorization requests must be reviewed by clinicians with relevant expertise, reducing delays and denials based on insufficient understanding of the specific medical needs.
  • Longer authorization validity: Prior authorizations will now be valid for the entire course of treatment and through a 90-day transition period when switching plans, reducing administrative burden and disruption for patients.
  • Oversight of utilization management: The rule establishes a stricter oversight process for MA plan utilization management programs, ensuring adherence to federal regulations.

Hospital Revenue Cycle: The Enforcers

While the rule itself is a positive step, its effectiveness depends on hospitals actively enforcing it. This is because:

  • Hospitals are the frontline: They are the first point of contact for patients facing denials for vital inpatient services from MA plans.
  • Activate a denial unit that focuses on the Medicare Advantage Plans
  • Identify your top 5 to 10 Medicare Advantage Plans;
    • Reach out to the Payers of the Plans to create an open line of communication
    • Review your Peer-to-Peer process for the Medicare Advantage plans.
    • Focus on denial prevention; review the claims and update the authorizations prior to submission.
  • Financial impact: Improper denials can lead to lost revenue for hospitals, further incentivizing them to advocate for their patients and enforce the rules.
  • Data collection and reporting: Hospitals have the capacity to collect and report data on MA plan denials and non-compliance, providing valuable evidence for CMS to hold plans accountable.

The Challenges Remain

Despite the progress, challenges still exist:

  • Internal compliance: Hospitals themselves may need to adjust their internal processes and training to ensure alignment with the new rule.
  • Collaboration and communication: Effective communication between hospitals, MA plans, and CMS is crucial for smooth implementation and dispute resolution.
  • Monitoring and enforcement: Robust monitoring and consistent enforcement by CMS are essential to deter violations and ensure the rule’s effectiveness.
  • Training

Moving Forward:

The CMS rule marks a significant step towards ensuring patient access to quality healthcare and holding MA plans accountable. However, its success is contingent upon hospitals actively playing their role as enforcers. By advocating for their patients, reporting non-compliance, and adapting their own practices, hospitals can ensure the rule’s effectiveness and create a more equitable healthcare system for all.

Tired of fighting tooth and nail for fair Medicare Advantage reimbursement?

The new CMS rule offers hope, but the battle isn’t won yet. Hospitals need a champion in their corner, not just another rulebook. Sunlit Cove Healthcare is that champion. We stand beside you, providing the process improvement, policy and procedure development, and comprehensive training needed to confidently navigate the new regulations and hold MA plans accountable.

Let's streamline your revenue cycle, empower your staff, and maximize your reimbursements. Don't just hope for compliance, take control with Sunlit Cove as your expert partner. Contact us today and discover how we can help you turn the tide in the fight for fair healthcare.
For more information on how Sunlit Cove Healthcare Consultants can bolster your hospital's collection capabilities, contact us, email Lori@Sunlitcovehealthcare.com or give us a call at (727) 278-3009! Optimize your revenue cycle, empower your collectors, and elevate your financial success!

Start today and schedule your free process review!

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Sunlit Cove Healthcare Consultants

We provide management and consulting services to help healthcare businesses run efficiently. Navigating the dynamic and complex revenue cycle management is a challenge for many health plans, health care vendors, and providers. Our consulting services are available to assist with your day-to-day operations and provide expertise in growth and change management. We manage all aspects of your enterprise from the development of the revenue cycle management process to the completion of your business cycle.