Medicare Advantage Issues Making Headlines

Medicare Advantage plans are being buffeted by bad news and regulatory challenges.

Last week produced a lot of Medicare Advantage (MA) news. Retired municipal workers of New York City are up in arms, as they are being forced to switch to a MA plan or pay an extra $191 a month to stay with traditional Medicare. Reports initially noted that many of these retirees who have been receiving care at prestigious places like Memorial Sloan Kettering (MSK) are now being told their care will not be covered, since that system is out-of-network. Other reports suggest that the retirees can see any medical provider that accepts Medicare, including MSK, as this MA plan was specially designed to allow payments to out-of-network providers at Medicare rates. The NYC teacher’s union has even established special web pages to try to sort out the confusion.

There was also word that Mayo Clinic will no longer see patients who are covered by a MA plan that is out-of-network, most notably UnitedHealthcare (UHC), which also happens to be based in Minnesota. Mayo Clinic is well-known for accepting patients from around the world for care, especially for patients with rare or difficult-to-treat illnesses, and the loss of access for these MA patients is unlikely to be readily accepted. And finally, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released another audit of an MA plan’s HCC coding that had a 73 percent error rate. The week was not kind to MA plans.

Hospices were also in the news last week, and not in a good way. An OIG report looked at 10 years of claims and found some disturbing numbers. They noted a very large increase in the number of for-profit facilities, but what seemed to concern the OIG the most was the increase in Part B spending on patients enrolled with for-profit hospices for Part b services and durable medical equipment (DME) that were carved out of the hospice benefit, because the services were reported as unrelated to the patient’s terminal illness. The OIG promised more audits to come.

As we have seen with many areas that are selected for audit, it is difficult to know which issue came first. In this case, were the nonprofit hospices less familiar with the billing rules for unrelated services and underused them, but now the for-profit hospices are billing correctly, making the pattern appear suspicious, or is there truly misuse? Data patterns cannot answer that question; charts must be reviewed.  

Finally, there was an interesting case posted on one of the user groups I follow. The case management director posted that “We are having challenges with one insurer, not UHC, that denies every inpatient stay if the patient is here for less than three midnights. Example: a patient [was] admitted for respiratory failure with hypoxia and placed on BiPAP. We discharged her on day three. Peer-to-peer [contact] attempted, but the payer medical director will not even discuss the case, citing their short-stay policy.”

Amazingly, that payer’s policy is online, and it states that “It is our policy that inpatient hospital stays on day three and beyond are medically necessary when supported by nationally recognized clinical decision support tools. The only exceptions are inpatient-only surgeries, patients admitted to an intensive care unit who met criteria for ICU admission, and patients whose length of stay was shorter because they died, were transferred, or left AMA, as long as they met inpatient criteria during their hospital stay.”

So, what happened here? Well, this hospital has a contract with this payer, and the contract holds them to the plan’s published policies. The hospital leadership signed the contract, so everyone has to abide by it. It doesn’t seem rational to have a patient in observation for three days, but as long as the patient is getting the necessary medical care, the issue really is about the payment.

It occurs way too frequently that such clauses get overlooked in contract negotiations, which often concentrate on payment rates, without realizing that the excellent negotiated rate may never get paid, since other clauses prohibit submitting such a claim.

Programming Note: Listen to Dr. Ronald Hirsch every Monday on Monitor Mondays as he makes his Monday rounds, sponsored by R1 RCM.

Facebook
Twitter
LinkedIn

Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, and the National Association of Healthcare Revenue Integrity, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

2026 IPPS Masterclass 3: Master MS-DRG Shifts and NTAPs

2026 IPPS Masterclass Day 3: MS-DRG Shifts and NTAPs

This third session in our 2026 IPPS Masterclass will feature a review of FY26 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 14, 2025
2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

This second session in our 2026 IPPS Masterclass will feature a review the FY26 changes to ICD-10-PCS codes. This information will be presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 13, 2025
2026 IPPS Masterclass 1: Master ICD-10-CM Changes

2026 IPPS Masterclass Day 1: Master ICD-10-CM Changes

This first session in our 2026 IPPS Masterclass will feature an in-depth explanation of FY26 changes to ICD-10-CM codes and guidelines, CCs/MCCs, and revisions to the MCE, presented by presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 12, 2025

Trending News

Featured Webcasts

The Two-Midnight Rule: New Challenges, Proven Strategies

The Two-Midnight Rule: New Challenges, Proven Strategies

RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.

June 19, 2025
Open Door Forum Webcast Series

Open Door Forum Webcast Series

Bring your questions and join the conversation during this open forum series, live every Wednesday at 10 a.m. EST from June 11–July 30. Hosted by Chuck Buck, these fast-paced 30-minute sessions connect you directly with top healthcare experts tackling today’s most urgent compliance and policy issues.

June 11, 2025
Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Substance abuse is everywhere. It’s a complicated diagnosis with wide-ranging implications well beyond acute care. The face of addiction continues to change so it’s important to remember not just the addict but the spectrum of extended victims and the other social determinants and legal ramifications. Join John K. Hall, MD, JD, MBA, FCLM, FRCPC, for a critical Q&A on navigating substance abuse in 2025.  Register today and be a part of the conversation!

July 16, 2025

Trending News

Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →

CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24