Medicare Advantage Plan Responds to CMS Complaint – Sort Of

Well, one of our clients recently got me really excited.

They received a denial of an inpatient admission from a well-known Medicare Advantage (MA) plan and they appealed, per their contract. They had felt the MA plan was completely ignoring the provisions of the Two-Midnight Rule, so they used the Centers for Medicare & Medicaid Services (CMS) developed process to file a formal complaint (see that process here).

We have all talked about it, but they actually did it. I was excited to see the results.

So, what happened?

Well, the complaint was received by CMS, and then CMS forwarded it to the insurer, with instructions to reevaluate the denial. This particular case went to an individual whose title is Complaints to Medicare Case Manager. And she then sent the hospital a letter summarizing their findings. Let me read part of it, exactly as it is written:

“The provider submitted for reconsideration and it was received on June 20 and sent for first level reconsideration and the clinical review team to verify (sic) the not authorized (sic) denial however the clinical review team sent it back as an inappropriate referral and the letter requesting notes was sent to the provider on 6/21.

However the internal routing of this request from the appeals team to the reconsideration team did include the comment that stated attachments are available under clinical documents category using case ID of DT-538-4364-C (not the real case number) and these documents were never received and it also missed the note stating the denial should have been a 1253 denial for not medically necessary per payer review rather than the item/service not authorized denial that was applied to the claim as the correct denial would afford the provider a clinical review rather than an administrative one. This will have a formal coaching request sent for remediating this processing error as well as the one to the claims processor who applied the incorrect denial on the claim originally.”

The letter goes on to say “the case was set up and was incorrectly worked as an appeal when there had still been no clinical reconsideration review completed and then the appeal case was incorrectly upheld on an administrative level and that the letter sent to the provider was also an incorrect outcome for this denial.”

Then things really get good, because the letter goes on to say “The clinical determination was that the denial of the inpatient authorization request was denied correctly as the original request for authorization was at the correct level for an observation stay and then changed solely on the 2-midnight rule that per the federal register page 22191 CMS advises that is not enough to be the only things considered by the MA plans therefore the denial of the IP authorization request is valid.”

So, Complaints to Medicare Case Manager, if you are reading, did you know that a letter full of gibberish would be released with your name on it? Second, the MA plan (and you know who you are, and that I am talking about you), how can you allow such a letter to be sent, knowing that eventually I would be reporting on it in RACmonitor eNews and on Monitor Mondays?

Finally, I have asked the hospital to send this letter, which contains no personal health information (PHI), to CMS so they can see the disdain of one MA plan in responding to an official CMS request for a case review. This should not be acceptable by any standard.

The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM Inc.