Medicare Advantage Payer Trends and Compliance Challenges

This report outlines key trends affecting Medicare Advantage (MA) plans, focusing on compliance with the CMS Two-Midnight Rule, which mandates that hospital stays expected to last at least two midnights be classified as inpatient. The report details the challenges faced by hospitals due to MA plans denying inpatient status, which results in significant financial implications. It highlights that MA plans are admitting 4% fewer patients compared to traditional Medicare, despite similar patient populations. Additionally, the report discusses the increasing rates of final denials from MA plans, which are nearly double those from commercial plans, indicating a growing financial risk for providers. It also addresses the administrative burden created by requests for information (RFIs) from payers, which delay payments without changing claim outcomes. The report concludes with recommendations for hospitals to improve compliance and revenue protection strategies in light of these trends.