Last Week, the FAH sent a letter to CMS Administrator Chiquita Brooks-LaSure urging CMS to ensure that reconsideration of out-of-network Medicare Advantage appeals follows new MA coverage rules and to improve transparency, accountability, and accuracy in the reconsideration process through MAXIMUS, the Part C Independent Review Entity (IRE). 

FAH letter urges CMS to require MA plans to copy providers on all reconsideration communications between the MA organization and the IRE, share access to appealed cases on the MAXIMUS appeals portal, and allow providers to easily address gaps in the case file. Transparency on its own will create appropriate incentives for MA organizations to carefully and faithfully transmit the case file and give providers an opportunity to detect and cure any issues so that the IRE has the benefit of the complete case file—as required by CMS regulations—when making its determination. 

The letter also urges CMS to clearly instruct MAXIMUS to review provider appeals using Medicare FFS coverage and payment rules, including the Two-Midnight Rule, Inpatient Only List, case-by-case exceptions, and DRG assignments.

Read the letter here.