The HPMS memo released yesterday is a significant signal for changes to come, especially when viewed through the lens of the 2024 MAPD Final Rule (CMS-4201-F) and the recently released 2024 Readiness Checklist. It’s a call to action for all compliance officers and Utilization Management (UM) departments to unite and upgrade practices in line with the latest criteria.

Unveiling UM Criteria Changes

  • Transparent Clinical Decisions: Plans are encouraged to align with traditional Medicare’s coverage criteria, ensuring transparent and evidence-based clinical decisions
  • Flexible Internal Criteria: In cases where standard Medicare coverage criteria isn’t fully established, Medicare Advantage (MA) organizations have flexibility for internal criteria based on current evidence in widely accepted treatment guidelines or clinical literature — but prepare your defense strategy
  • Simplified Prior Authorization: The rule streamlines prior authorization, including a minimum 90-day transition period for enrollees switching to a new MA plan amidst an ongoing treatment, aiming to minimize disruptions

Actionable Steps Post-Memo

  • Strategic Conversations: Engage in meaningful dialogues with your CMS account managers starting November, 2023. It’s an opportunity to ensure your understanding and compliance before the focused audits kick in
  • Prepare for Focused Audits: The 2024 focused audits are around the corner. It’s crucial to ensure your UM practices are in sync with the 2024 MAPD final Rule guidelines (CMS-4201-F)
  • Annual UM Tools Review: Make it a routine to review your UM tools annually as emphasized in the memo

Fostering UM and Compliance Synergy

  • Compliance officers, it’s time to deepen your collaboration with UM departments. The memo underscores the importance of working hand-in-hand to implement the updated guidance seamlessly.

Navigating regulatory transitions can be complex, but with ATTAC by your side, you have a knowledgeable partner to help unpack the intricacies of the upcoming changes. Your proactive steps today shape a compliant and robust healthcare landscape for tomorrow. Contact us and we’ll make a positive impact together.