Insights

In a recently released Care Decision Insights, Humana announced that 145 formerly inpatient-only procedures are now approved at the outpatient level of care. According to Humana, the Centers for Medicare and Medicaid Services (CMS) says that its current inpatient-only list applies to traditional Medicare–but not Medicare Advantage (MA), freeing Humana to designate changes within MA policies.

This poses significant challenges for healthcare organizations, as Humana’s position could cause claim processing and reimbursement issues surrounding the 145 listed procedures if they are conducted and billed at the inpatient level of care for MA plan members. If other insurance companies and benefits administrators follow suit, facilities could face continued challenges when attempting to bill for procedures that are no longer relegated to inpatient status.

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One of the most notable points of contention with Humana’s assertion that the CMS inpatient-only list doesn’t apply to MA plans is that it could be at odds with CMS guidelines and federal regulation. The inpatient-only list was codified in the Federal Register Vol. 65, No. 68 / April 7, 2000 Rules and Regulations, which indicates that the list represents national Medicare Policy. Additionally, according to the Medicare Managed Care Manual, “MA plans must provide their enrollees with all basic benefits covered under original Medicare.”

MA plans may not impose limitations that are not present in traditional Medicare—and the inpatient-only list is considered an inherent part of traditional Medicare policy. This means that if any of Humana’s 145 outpatient procedures are on the CMS inpatient-only list, they must be provided the same coverage in MA plans as in traditional Medicare plans.

In requiring that a hospital perform an inpatient-only procedure on an outpatient basis, Humana is restricting the benefits for their Medicare beneficiaries beyond those imposed by traditional Medicare. Fortunately, many hospitals’ managed care contracts with MA plans have provisions that require the MA plan to adhere to federal regulations and CMS guidance. Refusal on the part of the MA plan to comply with the CMS-issued coverage guidelines may be considered a breach of the managed care contract with the hospital.

If your facility faces barriers to reimbursement due to Humana’s latest Care Decision Insights, reach out to our team. Today’s hospitals should closely monitor developments surrounding the CMS inpatient-only list. CMS recently introduced a proposal to phase out the list by 2024—and every change will affect your claims and RCM processes.

When you partner with Aspirion, our experienced group of legal and hospital professionals commit to finding your hard-earned dollars in a churning sea of processes, policies, and payors—and we’ll make sure you get the reimbursement you’re owed.