HJNO Sep/Oct 2024

MEDICARE ADVANTAGE DENIALS 16 SEP / OCT 2024 I  HEALTHCARE JOURNAL OF NEW ORLEANS   discharged to a post-acute setting.” 13 These transfer delays also contribute to the overcrowding of emergency depart- ments. “An example is a patient who is on a regular floor bed who needs to go to post- acute care,” said Baton Rouge emergency physician John Jones, MD. “I need that bed for my next congestive heart failure patient who’s in the emergency department, and I can’t put them in there because it’s being occupied by somebody who’s waiting three days over the weekend to get placed.” CARDIOLOGY AND CANCER CARE MAplans also deny care for patients who need high-quality, Medicare-covered cardi- ology and cancer care services. Cardiologist Joe Deumite, MD, in Baton Rouge, offered two examples. In one case, Humana twice denied care to a man who needed a pacemaker. “He had 73 episodes where his heart paused for more than three seconds and several episodes where his heart paused for up to 5.2 seconds,”he said, adding that the care was finally approved by an independent review entity. In another instance, Deumite said a woman who suffers from irregular heart rhythms has had to go to the emergency room and take medications because Humana denied her appeals to receive a cardiac ablation. “There are several heart rhythms that respond to ablation, where you just slide up a catheter and cauterize a cir- cuit, and its curative.” In April, Baton Rouge medical oncolo- gist Gerald Miletello, MD, recorded a social media video testimonial where he described a dangerous care delay for one of his lung cancer patients. 14 “A six-week delay is not following the guidelines because you can easily die with stage four cancer in six weeks,” he said. Radiation oncologist William Russell, MD, in Baton Rouge, said his patients have faced delays when they need to start con- current chemotherapy with radiation. He also criticized MA plans’ requirement that he conduct a CT scan before they approve a PET scan. “You have to do diagnostic tests that are not going to be as relevant as the one that you wanted,” he said. “It costs the payers more money to go through that pro- cess.”The 2024 MA rule prohibits this prac- tice of step therapy for non-drug services. Medical oncologist Michael Castine, MD, in Baton Rouge, said MA plan documenta- tion requests require him to factor in 10 days between planning and implementa- tion of a patient’s cancer treatment. He men- tioned risks for patients with small cell lung cancer, aggressive lymphomas, or risks of brain metastasis, warning that “a delay of treatment by a week or two might actually change the whole plan.” PEER-TO-PEER FRUSTRATIONS Physicians also criticized the quality of communication they received from MA plan physicians when they call to appeal a patient-care denial. “They’re making it up as they go along,” said physical medicine and rehabilitation physician Adam Carter, MD, who serves as medical director of ClearSky Health Rehabilitation Hospital in Flower Mound, Texas. “I see them as constrained by their employer.” “You can almost tell by the first 10 sec- onds into your conversation whether it’s going to work or not, because you can tell whether that physician is reasonable,”Deu- mite. “They’re looking at year-and-a-half- old guidelines.” POLICY SOLUTIONS FOR IMPROVING MEDICARE ADVANTAGE Federal leaders have designed a broad range of solutions to help hold MA plans more accountable. Some changes will not begin until 2026, and stakeholders want additional timeliness and transparency requirements for meaningful patient care improvements. TIMELINESS Today, MA plans must make a prior authorization decision within 14 business days for standard requests and 72 hours for expedited or emergency requests. In 2026, the deadline for standard requests will become seven business days. Stakehold- ers have called for a 24-hour deadline for emergency requests; pending federal legis- lation would suggest, but not require, CMS to institute such an expedited timeline. 15,16 REPORTING In 2026, MA plans must begin publicly reporting aggregate contract-level prior authorization metrics, including denial rates and timeliness. Much of this informa- tion already exists today. According to KFF, MA plans denied 3.4 million prior authori- zation requests in 2022. Only 1 in 10 denials were appealed, but more than 8 out of 10 appeals resulted in overturning the denial. With limited data, it’s not possible to deter- mine the initial reasons for these improper care delays. A study by Premier found that MA denials are more common for higher cost treatments, and that hospitals’average administrative cost to fight these denials is nearly $20 billion a year. 17 Federal leaders, including Louisiana’s U.S. Sen. Bill Cassidy, and multiple provider groups have asked CMS to require MAcom- panies to report more specific and mean- ingful data. 18,19 KFF researchers found that “substantial data gaps remain that limit the ability of policymakers and researchers to conduct oversight and assess the program’s performance, and for Medicare beneficia- ries to compare Medicare Advantage plans offered in their area.” 20 KFF also found that “without plan-level data, by type of service, it will not be possible to determine whether plans are complying”with the 2024 MArule. KFF also reported that MAcompanies “do not report the reasons for prior authoriza- tion denials to CMS. If most denials of prior authorization requests are because the ser- vice was not deemed medically necessary,