Recent OIG Study Shines Spotlight on Medicare Advantage Plans’ Payment Practice

Elizabeth E. Hogue, Esq.

Enrollment in Medicare Advantage Plans (MAPs) recently exceeded the number of beneficiaries in the Medicare fee-for-service (FFS) program. The number of enrollees in MAPs will undoubtedly continue to increase. In April of 2022, the Office of Inspector General (OIG) of the US Department of Health and Human Services (HHS) issued Report

What Experienced and New Nurses Want to Say to Each Other

Elizabeth E. Hogue, Esq.

health care services and requiring prior authorization and referrals for specialty services.

Since MAPs are paid on a capitated basis, the OIG is concerned that payments create incentives for MAPs to deny access to services and payment in order to increase profits. The purpose of the report was to assess the extent to which denied requests for preauthorization and payment met

Medicare Advantage Plans sometimes delayed or denied beneficiaries access to services even though the requests met Medicare coverage rules.

OEI-09-18-00260, “Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care,” concerning the payment practices of MAPs.

First, the OIG confirmed that MAPs must cover the same services as FFS. According to the OIG, MAPs must follow Medicare coverage rules that specify what items and services are covered and under what circumstances. MAPs may not impose limitations that are not present in FFS Medicare. The OIG also pointed out that MAPs may impose additional requirements, such as using in-network providers for certain

Medicare rules and would likely have been approved in FFS Medicare.

Based on this review, the OIG concluded that:

1. MAPs sometimes delayed or denied beneficiaries access to services even though the requests met Medicare coverage rules.

2. MAPs also denied payments to providers for some services that met both Medicare coverage rules and MAP billing rules.

3. Regarding prior authorization requests that MAPs denied, 13% met Medicare coverage rules and these services likely would have been approved for beneficiaries under FFS.

4. Common causes of denials of prior authorization requests included MAPs’ use of clinical continues on page 34

Becker’s Hospital Review recently reported about what new and experienced nurses/case managers would like to say to each other.

Dear Experienced Nurses/Case Managers, Here is what new nurses and case managers would like you to know:

• First, we are grateful. Thank you for answering question after question and all of the knowledge and experience you share with us.

• Technology now plays a very important role in our profession. All of us must continually adapt.

• Because of the pandemic, we often did not get the hands-on clinical experience with some skills. Please be patient with us.

• Treat us as individuals and help identify areas that need improvement for each of us.

• Remember that we are experiencing for the first time some of the things you have already seen, such as coping with the loss of a patient.

• We did not learn how to communicate and interact with patients and families in nursing school. Please help us.

Dear New Nurses/Case Managers, Here is what experienced nurses and case managers would like you to know:

• We often have decades of experience and been there, done that, seen and heard it all.

• We are willing to share advice about continues on page 35