Gastroenterology Coding Alert

Here’s what healthcare professionals are saying about the changes.

As gastroenterology coders, you likely process a slew of claims for Medicare beneficiaries. Like the rest of us, the feds are gearing up for life after the pandemic. The most recent regulatory changes aim to address issues uncovered during the COVID-19 public health emergency (PHE), as well as persistent challenges related to fairness, cost, and value. Here are the highlights to help you stay on top of industry changes.

Context: If you’ve been following the Centers for Medicare & Medicaid Services’ (CMS’) policymaking over the last year, you’ve likely noticed common themes running through the agency’s plethora of updates. With changes across its various value-based policies, CMS hopes to bolster consumer rights, promote equitable care with limited disruption, and increase coordination between providers and programs. The 2024 Medicare Advantage (MA) and Part D final rule fosters these ideals, cutting costs and paperwork — while ratcheting up accountability. Other tie-ins include regulatory and policy alignment with the Inflation Reduction Act and CMS’ Behavioral Health Strategy. The feds published the final rule in the Federal Register on April 12.

Part of that final rule includes facilitating patient access to information, and industry leaders are glad to see it. “People with Medicare deserve to have access to accurate information when making coverage choices, and to be able to get the care they need without excessive burden or delays,” said Meena Seshamani, MD, CMS Deputy Administrator and Director of the Center for Medicare in a release on the final rule. “The commonsense policies in this rule further our goals to advance health equity, improve access to care, and drive high-quality, whole-person care.”

Consider These 4 Key Points

With hot topics like prior authorization and access to care on CMS’ policymaking to-do list, it shouldn’t be a surprise that the MA and Part D final rule offers critical updates as well as a myriad of other changes. Here are four takeaways from the rulemaking to consider:

1. Expect increased scrutiny of plan marketing. CMS finalized policies to cut down on misleading marketing from MA or Part D plan schemes after congressional scrutiny of previous enrollment periods.

“Ads will be prohibited if they do not mention a specific plan name, or if they use the Medicare name, CMS logo, and products or information issued by the Federal Government, including the Medicare card, in a misleading way,” a CMS fact sheet says. “Further, the final rule strengthens accountability for plans to monitor agent and broker activity.”

2. Get ready for a health equity index attached to the Star Ratings program. Caring for the most vulnerable beneficiaries is a critical part of being a Medicare provider — and CMS wants to reward that and ensure future MA and Part D plan members see that outreach. The agency is adding a health index under the Star Ratings program, rewarding providers who give “excellent care” to underserved populations, CMS says. Other factors such as offering language assistance in various formats and “culturally competent” care are included in the policy.

Additionally, the final rule aims to “balance patient experience/ complaints measures, access measures, and health outcomes measures in the Star Ratings program,” CMS notes. This will allow for a more patient-centered experience, CMS hopes.

3. Prepare for prior authorization to get easier. CMS wants MA enrollees to receive the same level of care they would if they were insured under Traditional Medicare, especially when the care is medically necessary. That means improving coordination between providers while ensuring there are no care gaps.

“The rule streamlines prior authorization requirements and reduces disruption for enrollees by requiring that a granted prior authorization approval remains valid for as long as medically necessary to avoid disruptions in care,” CMS explains. The agency will “requir[e] Medicare Advantage plans to annually review utilization management policies, and requir[e] denials of coverage based on medical necessity be reviewed by health care professionals with relevant expertise before a denial can be issued,” the fact sheet expounds.

4. See the Inflation Reduction Act provisions. The cost of prescription drugs skyrocketed over the last decade, and the feds want to help eligible low-income patients under Part D. The Inflation Reduction Act required CMS to improve “access to affordable prescription drug coverage for approximately 300,000 low-income individuals” and was “outlined in President Biden’s new prescription drug law,” the fact sheet says.

CMS is expanding on those provisions with a “full low-income subsidy benefit … to individuals with incomes up to 150 percent of the federal poverty level who meet eligibility criteria,” the agency says.