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The Centers for Medicare & Medicaid Services has finalized its rules governing Medicare Advantage plans.  Of greatest importance to providers are the changes to the rules governing Medicare Advantage plans’ coverage and medical necessity determinations. As stated in the rules’ preamble, these changes “will ensure that MA organizations provide equal access to Part A and […]

The Centers for Medicare & Medicaid Services has issued its final rules for payments to Medicare Advantage plans for Calendar Year 2024.  The final rules phase in changes to the determination of risk adjustment payments to the Medicare Advantage plans intended to reduce overbilling by these plans.  Medicare Advantage plans are among the most profitable

Senator Elizabeth Warren (D-MA) has sent a letter to the Federal Trade Commission asking it to carefully scrutinize CVS Health’s proposed acquisition of Oak Street Health.

ProPublica has published its investigation into Cigna’s system for denying payment for claims as not medically necessary without review by a medical director in order to save itself millions of dollars. The report highlights the experience of one patient for whom Cigna denied payment for a blood test as not medically necessary – even though

On March 17, 2023, the Centers for Medicare & Medicaid Services issued new guidance for the Independent Dispute Resolution (“IDR”) process under the No Surprises Act for payment determinations made on or after February 6, 2023 for services provided after October 25, 2022.  The new guidance was issued in light of federal court decisions striking

The Drug Enforcement Administration (“DEA”) has published its long awaited rules on prescriptions of controlled substances via telehealth after the end of the COVID-19 Public Health Emergency (“PHE”). Federal law prohibits the prescription of controlled substances without an in-patient visit unless an exception, such as an established patient relationship, applies. During the PHE, the DEA

Gold carding programs are programs that eliminate or reduce prior authorization requirements for providers whose requests for prior authorization have consistently been approved and/or who have met other evidence-based criteria. In its recently published proposed rules for Medicare Advantage plans for the 2024 contract year, CMS encouraged Medicare Advantage Plans to implement gold carding programs,

A new report released by Crowe, LLP found that Medicare Advantage plans are much more likely than other payers to deny payment for inpatient claims. The report, entitled “Who’s picking up the check,” analyzed data from more than 1,700 hospitals. It found that Medicare Advantage plans denied 5.8% of inpatient admissions in 2022 compared to

The American Hospital Association has submitted comments strongly supporting the Centers for Medicare & Medicaid Services proposed rule changes governing Medicare Advantage plans beginning in the program year 2024. The proposed rule changes would codify CMS guidance that Medicare Advantage plans must follow traditional Medicare’s coverage guidelines and must not make medical necessity determinations based

The Centers for Medicare & Medicaid Services has ordered an immediate halt to payment decisions by Independent Dispute Resolution (“IDR”) entities under the No Surprises Act as a result of a February 6, 2023 federal court decision vacating the rules governing how out-of-network payment decisions are to be made. In addition, CMS directed IDR entities