Challenging Medicare Advantage Denials of PM&R Physician Services-Challenging Medicare Advantage Denials of PM&R Physician Services (enduring)

Challenging Medicare Advantage Denials of PM&R Physician Services (enduring)

Video Transcription

Video Summary

This webinar provides an overview of the new regulations issued by CMS to address the misuse and abuse of prior authorization by Medicare Advantage plans. The regulations require MA plans to make medical necessity determinations based on traditional Medicare coverage criteria and limit the use of internal and proprietary coverage guidelines. Plans must also establish internal procedures for developing coverage criteria, including evidence-based guidelines and public accessibility. Medical necessity decisions must take into account patient history, physician recommendations, and Medicare coverage criteria. The regulations also establish safeguards for prior authorization, such as time limits for decisions and prohibiting partial approvals. MA plans must have utilization management committees to review and approve coverage policies. The regulations also require that claims reviewers have appropriate expertise and qualifications. These new rules will help improve access to care and provide physicians with tools to challenge denials. The Academy encourages physicians to familiarize themselves with the regulations and use them in conversations with MA plans.

Keywords

webinar

regulations

CMS

prior authorization

Medicare Advantage plans

medical necessity determinations

coverage criteria

utilization management committees

claims reviewers