CMS’ Medicare Advantage Utilization Management Rule Sets A Terrible Precedent
I have mentioned the new 2024 Medicare Advantage (MA) Utilization Management (UM) rule in two of my blogs recently. But here is a relatively short one to drive home the idea that the rule sets a terrible precedent. What does the rule do? It takes external evidence-based criteria off the table in favor of the policies used in the traditional Medicare program. Unless a FFS policy is not fully established, an MA plan must rely strictly on the traditional FFS program criteria instead of outside evidence-based clinical criteria. “Fully established” is not well defined, but CMS likely will argue that the NCDs and LCDs are fully established except in some small and extreme circumstances. Let’s set my argument up with three points. First, the rule was a direct result of the aggressive lobbying by provider groups opposed to the growth of managed care in Medicare. The Biden administration is sympathetic
