Healthcare Associate Kristen Bond Dobson authored “CMS implements new regulations to restrict Medicare Advantage organizations,” published by the Health Care Compliance Association’s (“HCCA”) Compliance Today (October 2023 issue).

The article reviews the issues relating to Medicare Advantage inappropriately delaying and denying coverage of medically necessary care. The Centers for Medicare & Medicaid Services (“CMS”) issued new regulations earlier this year in response to increased frustration from healthcare providers.

The new ruling clarifies the following:

  • Medicaid Advantage organizations (“MAOs") must comply with general coverage and benefit conditions set forth in so-called “traditional Medicare” laws when making coverage decisions and medical necessity determinations;
  • The two-midnight rule, and the admissions criteria set forth in 42 C.F.R. § 412.3, apply to MAOs; and
  • Prior authorizations should be used only to confirm the presence of diagnoses or other medical criteria and ensure that the furnishing of a service or benefit is medically necessary. Additionally, prior authorizations must be valid for an entire course of approved treatment.

The HCCA’s Compliance Today is a monthly publication providing the latest insights on healthcare compliance issues and offers practical information for healthcare compliance professionals.

To read the article, please click here.