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MONDAY REPORT

OIG Says Medical Advantage Insurers Denying Necessary Care

Commercial insurer Medicare Advantage (MA) plans often inappropriately deny prior authorization requests and payment requests, thereby preventing or delaying Medicare beneficiaries’ access to medically necessary care, according to a report last week from the U.S. Department of Health and Human Service’s Office of Inspector General.

“Our case file reviews determined that [Medicare Advantage Organizations (MAOs)] sometimes delayed or denied Medicare Advantage beneficiaries’ access to services, even though the requests met Medicare coverage rules,” the OIG wrote. “MAOs also denied payments to providers for some services that met both Medicare coverage rules and MAO billing rules. Denied requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers.”

The health plans often denied prior authorization requests because they “used clinical criteria that are not contained in Medicare coverage rules … which led them to deny requests for services that our physician reviewers determined were medically necessary,” the OIG wrote. Another ruse the MAOs used, according to the report, was to claim “that some prior authorization requests did not have enough documentation to support approval, yet our reviewers found that the existing beneficiary medical records were sufficient to support the medical necessity of the services.”

The report particularly resonates with MHA members who have experienced numerous issues with denials and timely transitions of care throughout the pandemic.

The report also found that MAOs denied 18% of payment requests reviewed over the course of a one-week test period even though those requests did in fact meet Medicare coverage rules and MAO billing rules. That 18% total represents 28,949 denials that should have been approved. The OIG said if that denial rate were extended over one year, the total MAO faulty payment denials would total 1.5 million.

Mass. House Approves FY2023 Spending Proposal

Last Wednesday, the Massachusetts House of Representatives passed a $49.7 billion FY2023 budget proposal, adding $130 million to the bottom line over the House Ways and Means draft. The State Senate’s budget proposal, and the debate and vote on it, is expected this month.

Approved budget amendments of interest to the hospital community included ones to: provide $3 million to the Bureau of Substance Addiction Services for technical assistance and training to increase the number of providers delivering culturally, ethnically, and linguistically diverse services in communities of color; create a certified nursing assistant certification pilot program; and create a special commission to explore the renovation and expansion of the Mount Ida campus in Newton for the purpose of establishing a Massachusetts school of health sciences education and center for health workforce innovation. An MHA priority amendment filed by Rep. Mike Day (D-Stoneham) also passed. It expands the Health Policy Commission (HPC) review of behavioral health boarders and requires the HPC to examine and provide recommendations related to payer reimbursement for boarders.

State Creates Deaf/Hard of Hearing Interpreter After-Hours Pilot

The Mass. Commission for the Deaf and Hard of Hearing (MCDHH) is running a pilot program to make interpreters available outside of regular business hours, and on holidays and weekends, for deaf/hard of hearing individuals in emergency situations.

MCDHH’s CART and Interpreter Referral Team manages all emergency requests made to MCDHH during regular business hours. These include, but are not limited to rape kits, emergency restraining orders, car accidents, mental health crises, overdoses and emergency detox placements, reporting of a violent or other crime, COVID-19 and other medical emergencies, and arrests.

But because emergencies can happen at any time, CART providers and interpreters must be available at any time, which is why MCDHH is expanding its CART/interpreter referral coverage to include after hours (5 p.m. to 8:45 a.m.) Monday through Friday, and 24/7 on weekends and holidays on a pilot basis only through June 30, 2022. MCDHH will collect and analyze data during the pilot period to determine the level of need and to inform the creation of a permanent after-hours emergency service program.

For emergency referral coverage after hours, or on holidays or weekends, please dial (800) 249-9949. During regular business hours, the CART and Interpreter Referral Team will continue to handle all emergency requests made to MCDHH (617) 740-1600. Learn more here.

Transition – MelroseWakefield and Lawrence Memorial Hospitals

Kelly Corbi has been named president of MelroseWakefield Hospital and Lawrence Memorial Hospital of Medford. She will also serve as an executive vice president of Tufts Medicine. Most recently, Corbi served as the system COO for SolutionHealth in Southern New Hampshire. Prior to that, she served as the SVP and chief integration officer for LifeBridge Health, a five-hospital regional healthcare organization based in the Baltimore-D.C. area. Corbi has an MBA from Mount Saint Mary’s University and an undergraduate degree from Penn State University.

John LoDico, Editor