By Ronald Hirsch, MD, FACP, CHCQM, CHRI
Government Affairs Committee, American College of Physician Advisors

If you are a hospital or post-acute case manager, you have probably spent more time than you wish you had on working with Medicare Advantage plans to obtain authorizations for medically necessary care. Even though these patients are Medicare beneficiaries, each Medicare Advantage plan seems to have its own guidelines on what admission status and what care they consider to be “covered care.” Even in the midst of a pandemic, this issue has received a lot of attention from not only the Office of the Inspector General but also the Centers for Medicare & Medicaid Services themselves who, last year, asked for public comment on how to reform the Medicare part C program and received over 4,000 comments.

Well, the concerns of the provider community were heard and in mid-December 2022, CMS released a new proposed rule, CMS-4201-P, entitled “Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, Medicare Parts A, B, C, and D Overpayment Provisions of the Affordable Care Act and Programs of All-Inclusive Care for the Elderly; Health Information Technology Standards and Implementation Specifications.” At 957 pages, there was a lot to digest, but the important section is 36 pages long, entitled “Utilization Management Requirements: Clarifications of Coverage Criteria for Basic Benefits and Use of Prior Authorization, Additional Continuity of Care Requirements, and Annual Review of Utilization Management Tools (§§ 422.101, 422.112, 422.137, and 422.138).”

As with most Medicare rules, reading and understanding this 957-page rule can be a daunting task and I certainly do not advise any of you to start reading these rules in full this year. For that, count on your advocacy organizations to read the rules and find the pertinent sections and summarize them for you. As CMSA has a collaborative relationship with the American College of Physician Advisors, I am happy to be able to share this call to action with you.

CMS has asked for comments on this new rule, which would put into federal regulation that the Two-Midnight Rule for determining admission status applies to all Medicare Advantage plans and would codify the rules that all Medicare Advantage plans to follow CMS regulations on access to post-acute care that are used for traditional Medicare beneficiaries. But without your help, the Medicare Advantage plans, which prefer to use their own guidelines, may get their way, leaving us with the current puzzle of rules to follow.

To help you, the Government Affairs Committee of the American College of Physician Advisors has developed a comment template that you can use to write and submit your comment. Now you may think that CMS does not read comments, but I can assure you they do. I am a prolific comment submitter and often see my comments addressed in the final rule, often resulting in a change to the proposed rule.

You can access the template letter prepared by the American College of Physician Advisors by clicking here.  Please take the time to customize it. Tell your stories (without PHI of course!); make it personal. Describe how it affects our patients’ care and recovery from illness. Cut out the parts that are not important to you, if there are any. Then go to this link to submit your comment.

Let me add that I know many CMSA members work for insurance companies and may perceive this as a personal attack. Let me assure you it is not; your work is crucial to the health of all our patients. In addition, you likely see requests from providers for care that are clearly outside the standard of care and wish that we could walk in your shoes for a day. We hear you. When you need our help, just ask. Wouldn’t it be nice if there was one set of rules for every single patient?

Dr. Ronald Hirsch, MD, FACP, CHCQM, CHRI, is a vice president of regulations and education at R1 RCM Inc. He is the co-author of The Hospital Guide to Contemporary Utilization Review.

Interested in getting more involved in public policy advocacy? Register to participate in the CMSA Hill Visits program:

The CMSA 2023 Virtual Hill Visits take place the week of March 6, 2023, with Congressional meetings scheduled throughout the day on Tuesday, March 7th, Wednesday, March 8th and Thursday, March 9th. Participation in the CMSA Virtual Hill Visits program is open to all CMSA members at no charge.

During this advocacy event, you will meet virtually with Members of Congress and/or their health policy staff from your respective areas of the country to educate them about the importance of Case Managers and our role in improving patient health outcomes. This important event will help elevate the professional practice of case management and the immediate needs of case managers nationwide.