Responding to Aetna’s Payment Policy and TAVRs

The talk of the industry continues to be Aetna’s new policy regarding payment for inpatient admissions. If you have not heard, Aetna will approve all inpatient admissions for Medicare Advantage (MA) patients, but then only pay the inpatient rate for those patients who either have a stay of five days or more or when MCG^© inpatient criteria are met. The others will get paid at a lower rate.

Yes, this policy has been reviewed by the Centers for Medicare & Medicaid Services (CMS), and they have no problems with it, because it meets the Two-Midnight Rule. When you ask for inpatient admission approval, they are giving it. How much you get paid for that admission is a contractual issue. And since patients get admitted as inpatients and get their inpatient rights, CMS is reportedly fine with it.

Because it is contractual, this should be addressed by finance to change the terms of the contract. But until then, when a notice of inpatient approval with a lower-severity payment comes in, you should do several things.

First, if they issue the notice before the fifth day, but the patient remains hospitalized for necessary care on Day 5 or longer, inform them of that. They should retract the notice and approve payment at the inpatient rate.

But if five hospital days have not passed, provide them with updated clinical information. In fact, provide them updated clinical information every day. They likely will run criteria the first day, approve inpatient care, but then record that MCG inpatient criteria were not met, so payment would be at the lower rate. But then on Day 2 and Day 3, the patient may have new clinical findings, but Aetna has no way to know that unless you update them.

And you likely will have to remind them that MCG criteria specify that under the Two-Midnight Rule, a patient who has had two medically necessary midnights of hospital care meets inpatient criteria.

Moving on, it’s been a while since we have talked about National Coverage Determinations (NCDs). But one NCD came up recently. The hospital had a patient with aortic stenosis, with a transcatheter aortic valve replacement (TAVR) planned. The patient had severe aortic stenosis and was asymptomatic.

And herein lies the problem. The Sapien valves from Edwards Lifesciences are now Food and Drug Administration (FDA)-approved for use in this situation, and the medical literature supports its placement before symptoms develop. But the Medicare NCD still requires the patient to be symptomatic. And as we all know, NCDs are binding, and the claim will be denied if all the criteria are not met.

This is a very difficult situation for the doctors and hospital; they want to do the right thing for the patient, but they would either have to do it for free or require the patient to pay $80,000.

Now, luckily, CMS has reopened the NCD to consider adding asymptomatic patients and removing the requirement to report data to a registry. But the timeline provided suggests no decision for six months.

Now, if you are doing TAVRs, you might want to talk to your cardiologists about this. The comment period has closed, so for now, all they can do is wait and hope their asymptomatic patients remain asymptomatic. And for non-Medicare and MA patients, check the payer policy.

You can only hope they have adjusted their coverage policy to match the FDA indication and current standard of care.