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Premier Responds to CMS RFI on Medicare Advantage Data

Premier responded to a Centers for Medicare & Medicaid Services (CMS) request for information that seeks input on various aspects of Medicare Advantage (MA) data to inform the agency’s general efforts to strengthen its MA data capabilities and guide policymaking. The RFI builds on CMS’ previous solicitation for input on ways to strengthen the MA program, to which Premier responded with recommended data-driven policy changes.

As part of its response, Premier shared the results of a recent national survey of hospitals and health systems that revealed nearly 15 percent of all claims submitted to private payers for reimbursement are initially denied, including many that are pre-approved through a prior authorization process. MA plans denied initial claims submissions at a higher-than-average rate of 15.7 percent. The survey found that more than 54 percent of claims rejected by private payers were ultimately overturned and the claims paid, but only after multiple rounds of provider appeals that cost providers nationwide roughly $19.7 billion a year.

To address these issues, Premier recommends in its comments that CMS consider collecting data on:

  • The flow of Medicare premium dollars through vertically-integrated health plans to create additional transparency;
  • Payment delays and denials between MA plans and their in-network contracted providers to determine whether current health plan industry practices violate CMS’ expectations of network adequacy; and
  • Value-based payment arrangements that MA plans are entering into with providers.
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