CMS Rule Seeks to More Clearly Define Internal Coverage Criteria, AI-Driven Tools
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Dec 05, 2024
Multiple industry experts say the current administration’s last major Medicare Advantage and Part D rulemaking attempt was largely “business as usual,” with CMS expanding on policies of the Joe Biden presidency and digging further into persistent issues like utilization management (UM), misleading marketing and provider directory accuracy. And they say it’s likely that some — but not all — provisions will make it into the final rule, which would be released by the incoming Republican administration under President-elect Donald Trump.
“It certainly seems like this was written as if there was going to be another Democratic administration, as the overall trend of CMS regulatory policymaking in the last four years” has been to further regulate MA, observes Tricia Beckmann, principal with Faegre Drinker Consulting. “Some of the provisions are probably an overreach in so far as they don’t align with what we think is the posture of the Trump administration versus some areas that are potentially tricky,” such as UM and insurers’ reported use of artificial intelligence to deny claims, which has drawn concern from both sides of the aisle and from providers, she points out.
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