Have you heard the news? The Centers for Medicare & Medicaid Services (CMS) is cracking down on how Medicare Advantage Plans (MAPs) enforce medical necessity criteria for covered items/services. This includes limiting the MAPs’ ability to deny coverage for medically necessary items/services using internal or proprietary rules previously unpublished for the public to reference. This is a huge win for all healthcare providers and beneficiaries alike, but what does it mean? And what can we expect moving forward?
Historically, MAPs had been expected to cover all items/services that are covered under traditional fee-for-service (FFS) Medicare. Technically, most, if not all of them have been complying with this expectation. However, they have been enforcing internal payment restrictions in the form of stringent prior authorization or predetermination processes or proprietary policy language that have not been made available to the public. The lack of specificity in the Code of Federal Regulations allowed for a lot of individual interpretation and inference by the MAPs, resulting in far more coverage denials and restrictions to medically necessary care.