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Across the nation, over 30 million Americans are enrolled in a Medicare Advantage (MA) plan, more than half of total Medicare enrollment. As enrollment continues to soar, so does concerns from policymakers about issues such as overpayments, prior authorization, and how MA plans are marketed to seniors. Some Senators have called MA “the privatization of Medicare” and urged the Centers for Medicare and Medicaid Services (CMS) to reform the program. This month, the Biden Administration responded to those concerns by announcing their intention to improve MA transparency and releasing a Request for Information on how to improve the program. CMS is expected to continue making reforms to the program while Congress debates additional policy solutions. Office of Inspector General (OIG) Recommendations A report conducted by the OIG in 2022 found that about 13% of MA claims were inappropriately denied, with post-acute care services being the most subject to inadequate denials. Additionally, 18% of payment denials were for claims that met Medicare coverage rules and MA organizations (MAO) billing rules, which delayed or prevented payments for services that providers had already delivered. To remedy this situation, the OIG recommended for CMS to:

• Issue guidance instructing MA plans to examine and revise their procedures for making coverage determinations.
• Update its audit protocols to address MA plans’ use of clinical criteria.
• Direct MA plans to examine their processes for manual review and system programming and remediate vulnerabilities that may result in inappropriate denials.

Increased Federal Attention On MA The Biden Administration and leaders on Capitol Hill are increasingly interested in the sustainability and affordability of MA.

• CMS released an RFI seeking input from the public regarding increased sharing of MA data to improve transparency in the program. CMS wants comments on all aspects of data related to MA with a keen interest in:
  • Data-related recommendations related to beneficiary access to care including provider directories and network.
  • Prior authorization and utilization management, including denials of care and beneficiary experience with appeals processes as well as use and reliance on algorithms.
  • To view a summary of the RFI click here. AHPA is planning on responding to the RFI. If you would like to contribute to the comments, please contact Cook@AdventHealth.com.
• Last year, Senator Elizabeth Warren [D-MA] wrote a letter to CMS emphasizing how the system has become subject to fraud and abuse. Warren highlighted analysis that revealed that MA plans will ultimately cost Medicare beneficiaries $145 billion in increased premiums within the next decade.
• Last month, a group of 57 Senators sent a letter to CMS expressing support for the MA program. The Senators urged CMS to “consider the ongoing implementation of

program reforms finalized last year and provide stability for the Medicare Advantage program in 2025.” MedPAC’s Two Cents

• The Medicare Payment Advisory Commissions (MedPAC) is concerned with the rapid growth of MA plans. MedPAC has noted that MA plan enrollees cost the government 6% more than it spends on seniors enrolled in traditional Medicare — a projected $27 billion in 2023.
• They worry that MA might be too costly, with the potential for fraud, waste, and abuse. In last year’s report to Congress, MedPAC recommended updates to the program to increase payment clarity and operational transparency as MA continues to grow.
• MedPAC is paying particular attention to behavioral health access. The Commission recently commented on CMS’ notice of proposed rulemaking entitled “Medicare Program; Contract Year 2025 Policy and Technical Changes to the Medicare Advantage Program.” MedPAC recommended that CMS expand network adequacy requirements for behavioral health.