What’s Wrong Here: MA Plan Non-Compliance with IPO List

We are nine months into 2024, and there are still some Medicare Advantage (MA) insurance companies that are not abiding by the rules and regulations set forth by the Federal Register for Medicare in 2024.

I could dig in deep and tell you all of the issues that are happening with the MA products, but today I want to focus on the hospital processes that you may or may not have in place to make sure that you get paid properly for surgical procedures on the Centers for Medicare & Medicaid Services (CMS) Inpatient-Only (IPO) List. The rule includes that all MA plans need to abide by the IPO and reimburse (and use their cardholder benefits) correctly.

The IPO is a list of CPT® codes that cannot be billed in an outpatient setting. The list is published every year in the Outpatient Prospective Payment System (OPPS) Final Rule and takes effect on Jan. 1 each year. (Since it is published in the OPPS rule, I refer to this as the “Outpatient Never” list).

In November 2021, the OPPS Final Rule for 2022 came out, and the Centers for Medicare & Medicaid Services (CMS) notified us they were going to stop publishing and requiring inpatient-only settings for the purpose of billing procedures, reducing the list over the next two years. They removed around 500 CPT codes for 2022. 

Those of us who had wrestled with and were losing the ability to bill cases due to the billing level of care were skeptical, but cautiously optimistic.

Then came the pushback, and the realization that CMS had not followed their own rules around removing those CPT codes. So, in 2023, most of those came back on the list. And in 2024 (and now 2025) we have seen very few CPT codes removed, and more added. I know we don’t have the 2025 list yet, but make sure you watch for it; there were some eye procedures that have been proposed to be added.

Now comes the process problems with which we are all struggling. CMS is very clear that they expect patients to require an overnight stay, but that the overnight stay (i.e. room and board charges) is not absolutely necessary. 

In our organizations (as I am sure is the same as yours), we are finding our cath lab and our radiology department performing procedures on the IPO list, recovering those patients in their own departments, according to evidence-based best practices, and then discharging them to their homes. What a great process! We don’t want to admit those patients to an inpatient bed for an overnight stay if there are no reasons to. Again, CMS is clear that the procedure may not require an overnight stay, and since we are using the best evidence-based practices to make sure the patient is stable for discharge, good for us and great for the patient! But now our challenge is to make sure we get that almighty physician order for inpatient care during the time that the patient is in the procedure area (and then get the MA insurance company to provide an authorization, but that is for another time).

I am curious, who do you partner with in your organization to accomplish this? I think our best relationships have been formed with procedural areas over the past two years. Refreshing, honestly, because due to the pandemic experience, too many of the areas had good excuse to hide behind email and voicemail.

So now we are back out there, learning peoples’ faces. I do not know that this was the intended consequence, but I am happy to be back among the in-person meetings now in order to advocate for our Medicare and MA beneficiaries, helping them utilize their benefits correctly.

We are not at 100 percent yet, but we are getting there. There are many “old wives’ tales” about the intent of the IPO record being one of our downfalls. You know that there are so many rules to a completed medical record, and many physicians balk at the inpatient order, because of the rules they thought they would need to abide by for the inpatient chart.

Well, the rules did not change here. All of the pre-procedure requirements are there, regardless of setting. So, we have been re-educating all of our physicians on the fact that this does not affect the medical record.

And then we heard that Leapfrog gives surgeons a better star rating if they perform more outpatient procedures. That was what the doctors understood. And honestly, I could understand that, because even on their website, this is the information that is provided:

“Leapfrog informs healthcare decisions by putting the right information in your hands.”

We actually had some difficulty explaining this to our teams in order to have our proceduralists get comfortable with the actual almighty order of inpatient admission; we informed them that it was going to be OK.

I wonder what others have done in their organizations.

Would love to hear from you!