Allow me to preface this article by noting that I am not Dr. Hirsch – he’s traveling and asked me to fill in for him today. My name is Dr. Clarissa Barnes, and I am an internist, current President of the American College of Physician Advisors, and the Chief Medical Officer for South Dakota Medicaid.
Medicare gets a lot of attention from physician advisors – which is partially historic, owing to the conditions of participation that originated the utilization review (UR) committee and the administrative functions that gave rise to the physician advisor, and partially practical, given the large number of hospitalized patients with Medicare or Medicare Advantage (MA) plans. However, as any pediatric physician advisor will tell you, Medicaid is a significant player in the payor space.
Nationally, Medicaid is the largest payor for children and young adults. Medicaid covers 41 percent of all births and is the largest payor of long-term services and supports (LTSS), as well as the largest single payor of services to treat substance use disorders and services to prevent and treat HIV. I will admit that during my years as a physician advisor, I was relatively Medicare/Medicare Advantage focused. There was always plenty of work to do if you just focused on UR functions for the Medicare population. That being said, you’ll be selling yourself and your organization short if you’re not aware of the opportunities you have with Medicaid.
To that end, I wanted to make you aware of the Ensuring Access to Medicaid Services Final Rule (CMS-2442-F). This one is easy to overlook, especially if you’re inpatient-focused. However, hidden in it are a couple items to note. This rule requires states to publish fee-for-service (FFS) Medicaid fee schedule payment rates on a publicly available website. Even if your state is heavily managed, you still likely have some FFS portions, and knowing these rates will give you insight into what they’re expecting for their managed partners.
Additionally, FFS Medicaid will have to compare their primary care, OB/GYN, and outpatient mental health/substance use disorder services to Medicare rates and publish it every two years. And beyond the superficial renaming of the Medical Care Advisory Committees to the Medicaid Advisory Committees (MAC), they are establishing Beneficiary Advisory Councils (BACs) for every state, each comprised of beneficiaries/families/and/or caregivers. Information about MAC/BAC activities is going to be publicly available, including bylaws, agendas, minutes, membership lists, and meeting schedules – and at least two MAC meetings per year are going to be open to the public, with a public comment period.
The difference between trying to influence something at the federal level versus the state level is huge. This transparency is only going to make it easier for you to get access to state decision-makers. The best-case scenario is this: see if you can get on your state MAC. At the very least, start showing up for those twice-a-year public meetings.
For all the physician advisors reading this, I also wanted to remind everyone that the American College of Physician Advisors (ACPA) mentorship program, Cultivating Physician Advisor Leaders (CPAL), is currently open for applications for mentors and mentees at acpadvisors.org, through the end of this week.
You do have to be an ACPA member, but otherwise the program is free.
In the FY 2027 Inpatient Prospective Payment System (IPPS) Proposed Rule, the Centers for Medicare and Medicaid Services (CMS) has introduced a notable and potentially
In the first three parts of this series, we explored how payers analyze claims data, identify cases for additional scrutiny, and interpret the medical record
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