Medicare to enhance Medicare Advantage coverage decisions

January 1, 2024, the “Centers for Medicare and Medicaid Services begins restricting how Medicare Advantage plans use predictive technology tools to make some coverage decisions. “

Predictive technology uses computer software to determine how much care a Medicare Advantage plan customer may need. Thus, not taking in the full picture of each individual.

“Insurance companies using such tools will be expected to “ensure that they are making medical necessity determinations based on the circumstances of the specific individual,” the requirements say, “as opposed to using an algorithm or software that doesn’t account for an individual’s circumstances.”

In addition, “before denying coverage considered not medically necessary, another change requires that a coverage denial “must be reviewed by a physician or other appropriate health care professional with expertise in the field of medicine or health care that is appropriate for the service at issue.”

“Medicare Advantage plans, an alternative to the government-run, original Medicare program, are operated by private insurance companies.”

“Nursing home care (rehab) has been among the most frequently denied services by the private plans — something original Medicare probably would cover, investigators found.”


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