Medicare Program; Request for Information on Medicare Advantage Data

CMS

This request for information (RFI) seeks input from the public regarding various aspects of Medicare Advantage (MA) data. Responses to this RFI may be used to inform general efforts to strengthen Centers for Medicare & Medicaid Services’ (CMS’) MA data capabilities and guide policymaking.

To be assured consideration, comments must be received at one of the addresses provided below, by May 29, 2024.

CLICK HERE to learn more or to comment

Key Lawmakers Urge CMS to Curb Medicare Advantage Fraud, Abuse

McKnight’s Home Care | By Adam Healy
 
The Centers for Medicare & Medicaid Services should take swift action to “curb abusive practices” by Medicare Advantage plans, senators said in a letter sent Thursday. 
 
“The MA program is based on the premise that private insurance companies can and would administer Medicare coverage more cost-effectively — but it has failed to do so every single year,” Sens. Pramila Jayapal (D-WA) and Elizabeth Warren (D-MA) wrote in their letter. 
 
The Medicare Payment Advisory Commission has estimated that MA plans average receiving as much as 6% more per enrollee than traditional Medicare, the letter writers said. On top of that, MA plans also spend roughly 25% less on healthcare services per enrollee, they noted.
 
“It is imperative for CMS to rein in these abuses and protect Medicare coverage for
the seniors and people with disabilities who rely on it,” the senators wrote.
 
Jayapal and Warren recommended improvements in four areas. First, they advised CMS to augment base MA payments to offset overpayments due to favorable selection. Since MA beneficiaries are typically younger and healthier, they wrote, MA insurers may receive higher-than-average reimbursement from CMS while also paying out fewer claims, resulting in “gross overpayments.”
 
They also recommended CMS get more aggressive about recouping overpayments, implement a “network quality” measurement to MA plans’ star ratings, and limit insurers’ use of health risk assessments — which have been criticized for their lack of transparency.
 
Jayapal and Warren also noted MA plans’ use of artificial intelligence to “systematically deny care.” In November, UnitedHealthcare, the largest MA insurer, was alleged in a class action lawsuit to have used artificial intelligence tools to deny hundreds of patients post-acute care services, including home health.
 
Also on Thursday, CMS issued an extensive request for information seeking details about nearly all aspects of the MA program. They include care access data, prior authorization results, statistics related to patients’ outcomes and more. Still, Jayapal and Warren sought further enforcement action in their letter to the agency.
 
They gave qualified praise to steps CMS has already taken to limit overpayments.
 
Nonetheless, they noted, the Committee for a Responsible Federal Budget has projected that CMS will overpay MA insurers by as much as $1.56 trillion over the next decade. 
 
“As enrollment in MA continues to grow, CMS must take more aggressive action to ensure Medicare’s sustainability, protect taxpayer dollars, and curb abusive practices,” they said.

As Denials Climb, MACPAC Approves Recommendations for Managed Care Oversight 

McKnight’s Home Care | By Adam Healy

The Medicaid and CHIP Payment Advisory Commission on Friday approved seven recommendations to enhance congressional oversight of Medicaid managed care organizations as recent reports reveal startlingly high rates of prior authorization denials.

MACPAC’s recommendations aim to improve the prior authorization and appeals process by requiring MCOs to report relevant data to the Centers for Medicare & Medicaid Services. CMS would be required to release public reports on the data, as well as update regulations and create additional guidelines for MCOs’ use of prior authorization.

A recent investigation by the Office of the Inspector General found that 12.5% of prior authorization requests were denied by Medicaid MCOs, and about 2.7 million Medicaid beneficiaries were enrolled in MCOs with denial rates greater than 25%.

Thousands of prior authorization requests for elderly, chronically ill or disabled patients requiring home care were denied by MCOs, according to the report. 

“Few denials are appealed and little is known about the beneficiary experience,” Lesley Baseman, senior policy analyst at MACPAC, said during the Thursday meeting. “The appeals process is also challenging and burdensome for beneficiaries. Denial notices can be late in the mail and the content is often unclear, and beneficiaries encounter multiple barriers in accessing continuation of benefits.”

Part of the challenge, OIG’s investigation found, was that few guidelines for MCOs’ prior authorizations requests are currently in place.

States are not federally required to collect data on denials, continuation of benefits, or appeals outcomes, according to Baseman. Federal rules do not require states to assess clinical appropriateness of denials, she said, and they do not require that states publicly report information on denials and appeal outcomes.

OIG’s report also found that many MCOs employed staff who were not qualified to approve or deny requests, and most states lack safeguards to identify improper prior authorization denials.

Elon Musk Says the First Human has Received an Implant from Neuralink, but Other Details are Scant

MedicalXpress | By WYATTE GRANTHAM-PHILIPS and LAURA UNGAR

According to Elon Musk, the first human received an implant from his computer-brain interface company Neuralink over the weekend.

In a Monday post on X, the platform formerly known as Twitter, Musk said that the patient received the implant the day prior and was "recovering well." He added that "initial results show promising neuron spike detection."

The billionaire, who co-founded Neuralink, did not provide additional details about the patient. When Neuralink announced in September that it would begin recruiting people, the company said it was searching for individuals with quadriplegia due to cervical spinal cord injury or amyotrophic lateral sclerosis, commonly known as ALS or Lou Gehrig's Disease.

Neuralink is one of many groups working on linking the nervous system to computers, efforts aimed at helping treat brain disorders, overcoming brain injuries and other applications. There are more than 40 brain computer interface trials underway, according to clinicaltrials.gov.

Neuralink reposted Musk's Monday post on X, but did not publish any additional statements acknowledging the human implant. The company did not immediately respond to The Associated Press' requests for comment Tuesday.

Neuralink previously announced that the U.S. Food and Drug Administration had approved its "investigational device exemption," which generally allows a sponsor to begin a clinical study "in patients who fit the inclusion criteria," the FDA said Tuesday. The agency pointed out that it can't confirm or disclose information about a particular study.

Neuralink's device is about the size of a large coin and is designed to be implanted in the skull, with ultra-thin wires going directly into the brain. In its September announcement, Neuralink said the wires would be surgically placed in a region of the brain that controls movement intention. The initial goal of the so-called brain computer interface is to give people the ability to control a computer cursor or keyboard using their thoughts alone.

In a separate Monday post on X, Musk said that the first Neuralink product is called "Telepathy"—which, he said, will enable users to control their phones or computers "just by thinking." He added that intial users would be those who have lost use of their limbs…

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