By Brian Murphy
The struggle is real … in the battle of the American Hospital Association (AHA) vs. Medicare Advantage (MA) plans.
The AHA recently issued a lengthy letter to CMS demanding increased oversight of MA plans, which they claim are denying medically necessary care. The AHA cited a recent OIG report which found that an estimated 13% of prior authorization denials and 18% of payment denials should have been granted. It also urged the Department of Justice to establish a task force to conduct False Claims Act investigations into commercial health insurance companies that demonstrate patterns of payment denial.
Interesting stuff. It all points to the ongoing battle of private insurance coverage guidelines vs. Medicare. Of paying for treatment vs. the need for cost containment. And, who controls medical decision-making (because saying a patient should or should not have been admitted, or which diagnoses should be covered, is an insurance company deciding how patient care should be provided).
There is lots of meat in the letter. The AHA addresses hot button diagnosis sepsis, noting that MA plans are denying these claims on the basis of failure to meet sepsis-3 criteria, as opposed to the more sensitive/preventative sepsis-2 criteria many hospitals still use. They also requested that CMS close the loophole of allowing MA plans to submit diagnosis codes for risk adjustment purposes, and then denying payment to the provider for services to care for those diagnoses (seems quite reasonable to me).
Who is in the right here? As usual I’ll try to play Switzerland for a moment.
To defend MA, runaway costs are real, as evidenced by the Medicare trust fund running out (latest estimate without intervention: 2026). And, I very much agree that we should be driving patterns of care from acute interventions to less costly preventative measures. You can argue MA plans are doing both.
But, it’s impossible not to side with the AHA’s point of view, especially on the most egregious examples (for example, a 72-year old woman with a cancerous breast tumor. The MA plan denied her breast reconstruction surgery, stating “that the service was not covered”). It’s hard not to feel cynical about the motives of MA plans reaping large profits.
CDI, coding, and case management professionals can only do so much in this struggle of titans, but that includes following UHDDS guidelines and MEAT criteria to ensure care provided is also reflected in the record, and diagnoses are supported with clinical indicators and treatment. Follow the Official Guidelines for Coding and Reporting and make sure your principal diagnosis is the condition that bought the bed, and is not just the most expedient. Follow and prepare to defend your admission criteria, Milliman or InterQual etc. Don’t give auditors easy ammunition.
Regardless of who is “right,” the amount of resources and time spent on this fight is a crime in and of itself. Both sides must come to the table.
About the author
Brian Murphy is the founder and former director of the Association of Clinical Documentation Integrity Specialists (2007-2022). In his current role as Branding Director of Norwood, a mid-revenue cycle staffing and consulting firm, he enhances and elevates careers of mid-revenue cycle healthcare professionals. Brian can be contacted at [email protected]
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