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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

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Medicare Advantage Will Have Huge Challenges Ahead

Medicare Advantage (MA) has been known as the most profitable sector of any health plan. With high premiums, a lucrative Star quality bonus, and chance to reduce medical expenses compared to the traditional fee-for-service program, plans have been able to register higher percentage and overall dollar margins in MA as compared with commercial and Medicaid. But as we have seen throughout the last few years, MA is not without its challenges and that will continue into the future. Surprisingly, at least one major player could be shopping its Medicare Advantage portfolio and getting out of the business. Here are the top challenges I see and areas MA plans need to keep an eye on. The collapse of the insurtechs Just a few years ago, the insurtechs were the darlings of investors. Investors believed that the insurtechs would leverage technology to transform healthcare, reduce costs, and drive quality. The investors also

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