New Medicare Advantage Question and Complaint Process for Provider Organizations

The American Hospital Association (AHA) released a member advisory on August 20, 2024 about a new Medicare Advantage question and complaint process for provider organizations. The full advisory can be read below.

The Centers for Medicare & Medicaid Services (CMS) has published a new complaint form with instructions for Medicare providers seeking assistance from the agency in resolving Medicare Advantage (MA) claims issues. The complaint form is a cover sheet that must be submitted to CMS in a password-protected file, along with the requested documentation as indicated on the form, to the new CMS Drug and Health Plan Operations (DHPO) email at MedicarePartCDQuestions@cms.hhs.gov.

While CMS allocates MA program oversight across the agency’s ten regional offices, the agency will now receive and process all MA inquiries and complaints from providers through this centralized email. This will replace the current process of contacting CMS’ regional emails for MA complaints and questions.

For CMS to act upon cases submitted through the new email, the provider must:

• Include all information and documentation requested on the cover sheet.
• Refrain from providing additional documentation not listed on the cover sheet (such as medical records).
• Certify that an effort was made to resolve the issue with the MA plan before contacting CMS.

The complaint form cover sheet provides additional information to providers about the types of appeal complaints and claims payment disputes that can be submitted using this form and technical specifications for documentation submission requirements. While CMS reminds providers that its role is not to determine medical necessity or payment amounts for disputed cases, the agency will seek to identify trends in provider complaints to investigate and address broader issues with MA plans where appropriate. CMS specifies that upon receipt of a complaint, CMS staff will evaluate the case and, when appropriate, add it to the agency’s Complaint Tracking Module and respond to the provider organization with a complaint ID for reference.

In addition to the new DHPO email, hospitals and health systems may also send complaints about inappropriate utilization management criteria or claims processing approaches that they believe do not comply with CMS requirements to the CMS Part C and D Audit email at part_c_part_d_audit@cms.hhs.gov. This may include practices related to prior authorization, concurrent review or retrospective review to deny or downgrade coverage or payment that the provider believes is not permitted under CMS rules. These complaint types can be submitted to both the Part C and D Audit and the DHPO emails. Note that there is no cover sheets required for the Part C and D Audit email submission.

AHA TAKE

The AHA continues to be concerned about certain MA plan practices that inappropriately restrict or delay patient access to care. CMS codified important new policies in the calendar year 2024 MA final rule, which took effect Jan. 1, 2024, that have greatly increased oversight and accountability of MA plans and sought better alignment between Traditional Medicare and MA. The AHA strongly supports those policies and has urged CMS to increase MA oversight and enforcement to address continued gaps in compliance among certain MA plans.

The AHA has long advocated for establishing a more streamlined provider complaint and inquiry pathway so that providers can raise suspected violations of federal rules to regulators independent of contractual dispute resolution mechanisms. We applaud CMS’ efforts to create such a pathway for providers.

FURTHER QUESTIONS

If you have further questions, please contact Michelle Millerick, AHA’s director of health insurance and coverage policy, at mmillerick@aha.org.