More Grumblings from Dr. Hirsch

Let’s start today with a recent U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) notice about a fraudster who was paid almost $3 million by Medicare Advantage (MA) plans for durable medical equipment (DME) that was not ordered by a physician, needed by the patients, or even approved by the plan. Seriously, Medicare Advantage? You’ll pay a fraudster $3 million for DME you never approved, but you won’t pay hospitals for medically necessary inpatient admissions that meet the Two-Midnight Rule? Something is very wrong.

Next, I want to point out a major flaw in the upcoming Comprehensive Care for Joint Replacement Expanded (CJR-X) program, starting in 2028. I was trying to understand how the Centers for Medicare & Medicaid Services (CMS) was going to set the target rates for calculating savings, and realized that we are still in the baseline period for setting the target rate for the first four years of the program.

Now, why is that interesting? Well, hospitals will get to share in the savings if their 2028 spending is less than the target rate, which is calculated based on spending during a rolling period from 2023 to 2027. In other words, it is in your best interest to send as many total hip and knee replacement patients as possible to skilled nursing facilities (SNFs) and use as much home care and outpatient therapy as possible, so when January 2028 rolls around, you have lots of room to improve.

If you are working hard now to limit SNF use and optimize time receiving home care and outpatient therapy, then once the program starts, you’ll have little room to improve. And that means no shared savings for the program partners.

Now, should you game the system like this? Of course not, but CMS really needs to think about these programs that disadvantage those who are already high-performing.

Next, let me jump back to MA, this time singling out United HealthCare. They made headlines two weeks ago when they announced they were eliminating a large number of prior authorizations. Of course, they reveled in the adulation they received.

But the devil was in the details. If you went into the actual lists of procedures that will no longer need prior authorization, you will find that the lists are different for each type of plan. There are only 160 procedures coming off the MA list, with many of them relating to DME, but more than 800 coming off the commercial plan list.

They are not removing one single gastrointestinal procedure from the prior authorization list for MA patients. So, the physician office and hospital still have to determine what CPT® code is planned and check the specific list. And since the elderly need healthcare more than younger people, the burden reduction with this is less than impressive.

And finally, I direct my disappointment at both the Quality Improvement Organizations (QIOs). They are really underperforming. The first case reflecting this was an inpatient needing SNF care. The facility offered choice. Then, the  second Important Message from Medicare (IMM) was delivered, the patient was stable enough to transfer, and they had an accepting facility, but the family wanted more time to visit other facilities, hoping to find a facility with private rooms. So, the patient appealed.

And the QIO sided with the patient, noting, “due to not yet finalizing a placement in an appropriate and safe SNF, it is reasonable to continue acute-care stay.”

Seriously? This facility is CMS-approved, and it can meet the patient’s needs, plus it has an open bed, but that’s not good enough for the QIO?

The hospital is submitting a complaint to CMS.

Then that same QIO denied a MA patient’s discharge appeal because although they were admitted as an inpatient, the MA plan told the QIO they were denying inpatient status, so the patient has no appeal rights. That patient was still an inpatient, and it seems inconceivable that they would lose their appeal rights every time the payer says “we won’t approve inpatient care.”

Both the provider and I have a question submitted to CMS to find out the actual interpretation.

And finally, a QIO recently sided with a patient on their discharge appeal simply because the discharge summary was not available. The patient has not yet left the hospital! How can they demand a discharge summary?

That is absolutely improper.

Yes, the rules are complex, but the QIO is supposed to be the expert and properly represent the patient. This is disappointing, to say the least.