A reader responds to the CMS request for feedback on ways to strengthen Medicare Advantage plans.

On Aug. 1, 2022, the Centers for Medicare & Medicaid Services (CMS) formally posted a notice seeking feedback on ways to strengthen Medicare Advantage (MA) in ways that align with the Vision for Medicare and the CMS Strategic Pillars. Many of the readers of RACmonitor have strong opinions about Medicare Advantage and the panelists on Monitor Monday have often discussed the ambiguities in the regulations governing MA plans. One listener chose to share the comment she submitted to CMS and consented to allowing us to publish it.

As a seasoned utilization management nurse (more than 20 years) who has worked on both the payer and the provider sides of the industry, I have never before seen or experienced the diligence that Medicare Advantage plans have exercised this year to find loopholes and ways to (mis)interpret Medicare language to their advantage and to the disadvantage of Medicare members and providers. Here are a few examples:

Medicare Advantage plans are indeed taking advantage of Medicare/CMS, primarily through interpretation of either CMS language that is not clear, or misinterpreting language that is clear but which they can use to their advantage. The administrative burden of hospital providers in establishing process workflows just to be able to cope with MA plan rules and requirements is tremendous.

When an MA plan posts billions of dollars in profits year after year, while smaller hospitals close because of lack of resources to fight the abuse by MA plans, shouldn’t CMS pay attention and take a closer look at what is really happening on the front lines of the industry? 

The need for more intense scrutiny of MA plan practices, establishing clear guidelines for both payers and providers through transparent communication, and more stringent audits to ensure consistency between MA plan rules with CMS guidelines appear to be warranted. Several MA plans have even dropped their NCQA  accreditation for their Medicare product lines “because there is no regulation by CMS requiring accreditation” and more importantly, accreditation standards appear to be more stringent than CMS.

As a Medicare patient, I will never encourage friends and family to sign up for a Medicare Advantage plan. MA plans have great enticement advertising of “extra” or “supplemental” benefits. What Medicare patients do not know or realize is that if the current challenges that Medicare providers must endure continue, more hospitals may close, more practitioners may not want to participate in Medicare, and Medicare patients will end up paying more out-of-pocket costs.

In the bigger picture, the Medicare members end up losing the care they need and deserve.

If you want to read the request and submit a comment, comments must be submitted to CMS by Aug 31. – Ronald Hirsch, MD

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