Sunday, June 26, 2022

Nerd Note: Medicare Advantage Plans Don't Have to Follow Many Part B Rules; Example

There's a general principal that Medicare Advantage plans aren't required to follow the (tens of thousands of pages of) CMS Part B claims processing rules.   But sometimes it's nice to have a citation to that at hand.

Here's one.

In November 2021 rulemaking for CY2022, in the Physician rule, CMS discussed the uber-complex area of Appropriate Use Criteria (AUC) for advanced imaging.  This is software that clinicians are supposed to use when ordering e.g. MRI for back pain.  Much ink has been spilled over this since 2014 (start here), when it was introduced in the same legislation that created PAMA rules for lab pricing.

After another year of numbingly detailed rules and exceptions for AUC claims processing, CMS fields a question "Do Medicare Advantage claims require AUC information?"   86 Fed Reg 65235.

The answer is NO, but they MIGHT, and you have to check with each Medicare Advantage plan to find out.  (There are LOTS of Medicare Advantage plans, making this tedious.   But the general principal, you can cite to 86 Fed Reg 65235, 2021.  Fun fact: Kaiser says there are 3,834 Med Adv plans.

(For a really useful table of when commercial insurance follows, or don't follow, bundling rules similar to CMS for lab tests, see my June 2022 blog here.)

86 FR 65235