News

CMS ISSUES FINAL RULE: REVISED MEDICARE ADVANTAGE APPEALS PROCESS FOR ENROLLEES

WHAT YOU NEED TO KNOW

On April 4, 2024, CMS announced that Medicare Advantage (MA) appeals will parallel the same review process as traditional Medicare allowing MA plan enrollees to have access to the fast-track appeals process now.

Key elements include: Independent Review

1. The QIO, not the MA plan, will review fast-track appeals of the plan's decision to terminate Skilled Nursing Facility (SNF) services.
2. Enrollees will not have to forfeit their right to an appeal when they leave a facility.

Significance:

• The ability to escalate an appeal to an Administrative Law Judge (ALJ) is crucial for providers and beneficiaries looking to reinstate coverage, especially when care has been delivered before denial.
• An ALJ hearing is the best opportunity to demonstrate continued medical necessity and skilled services.

Additional information on the revised Medicare Advantage appeals process for enrollees can be found here.

Preferred Therapy Solutions continues to provide vital information that may impact rehabilitation management, reimbursement policies, and clinical programs, supported by compliance and regulatory requirements that are necessary for a thorough understanding of practices and procedures. If you have any questions, contact Barb Blatt, Director of Compliance and Appeals Management at bblatt@preftherapy.com