Scrutiny of MA Plans Continues Nationwide

CMS used secret shoppers to call phone numbers advertised on television and discovered a lot of incorrect information and attempts by the agents to coerce enrollment.

I am recently back from a visit out west. I want to give a shout-out to the health information management (HIM) professionals who attended the Oregon Health Information Management Association meeting on Saturday in Albany, Oregon and heard me speak. We all had a delightful time. It was especially rewarding when I was approached by an attendee who told me how much they enjoy listening to Monitor Monday, and how useful they find the information.

My objective was to familiarize the attendees with some of the concepts of utilization review (UR), so they can at least have an awareness of the work of their colleagues. During the session I did my best to explain the two-midnight rule in language that would make sense to a non-UR person, but I could still see a slight glaze over their eyes.

On the other hand, when I discussed the games that the Medicare Advantage (MA) plans and commercial insurers play in denying everything possible, they all vigorously nodded, with clear understanding of the issue.

Speaking of MA plans, I know that Monitor Monday and RACmonitor have been talking a lot about them – but so is everyone else. This last week they got more bad news: first, Mayo Clinic in Florida and Arizona has announced that it will not see patients with MA plans for scheduled care. I have heard rumors that there are a lot of old people living in those two states, so that could be a big blow to the MA sales efforts for the thousands of residents who receive world-class medical care at Mayo Clinic.

Second, despite recent rumors of his death, Jimmy “J.J.” Walker is still alive and well, and selling MA plans on television, along with other celebrities such as William Shatner. And it appears that the Centers for Medicare & Medicaid Services (CMS) is not happy about some of those celebrity ads. CMS actually used secret shoppers who called those phone numbers and found a lot of incorrect information, and attempts by the agents to coerce enrollment. They also noted that they “are concerned recent national television advertisements promoting MA plan benefits and cost savings, which may only be available in limited service areas or for limited groups of enrollees, overstate the available benefits, as well as use words and imagery that may confuse beneficiaries or cause them to believe the advertisement is coming directly from the government.”

As it stands now, MA plans must submit their advertisements to CMS for review, and after five days they may begin using the material unless CMS objects under what is called the “File and Use” process. But CMS has announced that starting in 2023, the agency will review all television advertisements used by MA plans for marketing under a 45-day timeframe, increase their oversight of all other advertising, and investigate more complaints by listening to the call recordings to see if misleading information was provided.

Now, just to be fair, many of these misleading practices may be from independent agents, but the buck stops at the top – so the MA plans themselves will face the consequences, and rightly so.

Changing topics to something more clinical, a recent clinical trial was released that may get some attention in the world of pain management. Patients who had a spinal nerve stimulator implanted were randomized to trials of spinal cord burst stimulation or placebo stimulation, and pain relief was equivalent.

While I am sure this will be carefully scrutinized, the possible conclusion is that, as we saw with kyphoplasty in the VERTOS trial, the sham procedure may be as effective as the actual treatment at controlling pain. It will be interesting to see how payers and physicians react to this.

Programming note: Listen to Dr. Ronald Hirsch every Monday when he makes his Monday Round live on Monitor Mondays, 10 Eastern and sponsored by R1_RCM.