General Surgery Coding Alert

“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 5 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 five 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. 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. In response to recent Office of Inspector General (OIG) reporting that MA plans’ improper denials could bar or delay beneficiaries from receiving medically necessary care, the final rule establishes “minimum standards for an acceptable benefit design ... in addition to establishing important [beneficiary] protections.”

To that end, the final rule states, “[s]imilar to MACs in Traditional Medicare, we expect MA organizations to make medical necessity decisions based on NCDs, LCDs, and other applicable coverage criteria... to determine if an item or services is reasonable, necessary, and coverable under Medicare Part A or Part B. The MA plan may still apply utilization management practices, but must limit the coverage criteria used to deny coverage for an item or service so as to make accessible the basic benefits.”

Also, “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.

3. 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.

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.

5. Understand how CMS plans to expand behavioral healthcare for MA enrollees. In March 2022, the Biden administration announced an initiative to address the mental health crisis. Since then, ideals from the five-prong CMS Behavioral Health Strategy have been implemented in rules across the various parts of Medicare.

In the MA final rule, CMS is “adding clinical psychologists and licensed clinical social workers to the list of evaluated specialties” to beef up network adequacy in plans; solidifying wait time standards before receiving behavioral health services; and “ensuring that behavioral health care is a core part of person-centered care planning,” the agency says.

Industry Orgs Weigh In on Changes

American Medical Association (AMA) President Jack Resneck, Jr., MD, cheered CMS’ efforts to update MA and Part D, particularly on prior authorization. “The AMA applauds CMS Administrator [Chiquita] Brooks-LaSure]for leading the effort to include provisions in this final rule that will ensure greater continuity of care, improve the clinical validity of coverage criteria, increase transparency of health plans’ prior authorization processes, and reduce care disruptions due to prior authorization requirements,” Resneck said in a release.

The American Hospital Association (AHA) found many positives among the policies but urged CMS to maintain transparency and scrutiny of MA and Part D plans. “The final rule includes helpful provisions to ensure more consistency between Medicare Advantage and Traditional Medicare by curtailing overly restrictive coverage policies that can impede access to care and add cost and burden to the health care system,” said Ashley Thompson, AHA Senior Vice President of public policy analysis and development, in a release. “The AHA will continue to carefully review the final rule and urges the agency to conduct rigorous oversight and enforcement to ensure meaningful compliance.”

Resource: Find the final rule at www.govinfo.gov/content/pkg/FR-2023-04-12/pdf/2023-07115.pdf.