In the current situation, MA plans have a significant financial incentive to ignore and disregard hospitals until actions are time-barred. While the obvious and primary impact of such tactics may be these underpayments owed to 340B hospitals, the long-term consequences of such tactics from MA plans may impact Medicare Advantage beneficiaries’ continued access to care.

As is known in the healthcare industry, providers and hospitals are exhausted with the costly and administratively burdensome tactics employed by MA plans. From reimbursement cuts to denied and delayed payments to not following Medicare coverage guidelines as required, many providers and facilities are increasingly and understandably choosing not to contract with MA plans or to terminate existing agreements.

As Medicare Advantage enrollment grows, it becomes increasingly important to ensure that MA plans tactics that limit or hinder efficient reimbursement are curtailed so that Medicare Advantage beneficiaries continue to have access to medically necessary care.

Ensure your organization has:

• Sufficient controls and audit practices in place to identify potentially fraudulent activity for private or other non-public healthcare payers in addition to federal healthcare programs
• A robust compliance program with whistleblower protections, including non-retaliation policies, and that such programs include prompt and meaningful investigations of reported concerns with follow-up to the whistleblower

For more information on how an effective compliance program should be structured, review the General Compliance Program Guidance issued by the Department of Health and Human Services (HHS) Office of Inspector General (OIG) in November 2023.

Among the seven elements of a compliance program, HHS OIG recommends there be appropriate training and education of requirements and that there be effective lines of communication between the compliance officer and entity personal to reduce the potential of fraud, waste and abuse. Having these measures in place across your organization for all types of payers will reduce your organization’s risk for criminal or civil forfeiture under this new program.

Lastly, if your internal investigation discovers problematic conduct involving private health insurance plans, then the DOJ’s temporary amendment to its Criminal Division’s Corporate Enforcement and Voluntary Self-Disclosure Policy (CEP) allows companies who receive a whistleblower’s report internally to qualify for the presumption of a declination under certain conditions. In such cases, review with your legal counsel to determine your next steps.

An Act to Provide for Consistent Billing Practices by Health Care Providers:
This new law requires that claims for facility services submitted to health insurance carriers identify the physical location where services are rendered, including hospital off-campus locations.

An Act to Amend the Maine Insurance Code Regarding Payments by Health Insurance Carriers to Providers:
This new law restricts health insurance carriers to filing notices of a proposed amendment to a provider agreement to only four time per calendar year: on January 1, April 1, July 1 and October 1.

If the proposed change is to a reimbursement policy and it will impact more than $500k per year to participating providers, then the notice must include the carrier’s good faith estimate of the total annual financial impact to all participating providers in the state.

Carriers will need to furnish the participating provider with both a clean and redlined copy of the provider agreement being changed. This bill also shortens the time limits for carriers to retroactively deny previously paid claims to not more than 12 months. Situations exempt from the 12-month timeframe will now be subject to a 36-month limit.

An Act to Protect a Patient’s Access to Affordable Health Care with Timely Access to Health Care Prices:
This new law requires health care facilities and practitioners to post a notice informing patients of the right of an uninsured patient to request information about the price of medical services, and to include the notice in the consent-to-treatment form that patients sign before receiving health care services. Upon request of an uninsured or self-pay patient, the new law requires facilities and providers to furnish a good faith estimate of the cost of medical services for that single encounter within specified timeframes.

To a certain extent, these requirements align with current requirements under the Federal No Surprises Act (NSA), and a health care entity does not violate this state law if it complies with NSA requirements. If the provider fails to give an uninsured or self-pay patient a good faith estimate upon their request, then the provider is prohibited from initiating or pursuing any collection action against that patient for those items or services.

This new law also requires the provision of a description of services for a single encounter to insured patients upon their request. The description must include the CPT codes for the services and a notification that the patient may use the estimate to obtain an estimate of their out-of-pocket costs from their health insurance carrier. Carriers are then required to respond to requests from a patient for an estimate based on the description and codes given by the provider.

Lastly, the new law requires hospitals to comply with federal price transparency requirements.

An Act to Prohibit Unfair Practices Related to the Collection of Medical Debt:
This new law prohibits unfair practices related to the collection of patient medical debt, including the collection of any interest or fees on the debt.

If pursuing litigation to compel payment of medical debt, the new law requires providing the patient with a certain written notice indicating that litigation may not be pursued when the consumer’s household income is not more than 300% of the federal poverty level, and then allowing the consumer 30 days to respond and provide evidence of their income.

An Act Concerning Prior Authorizations for Health Care Provider Services:
This new law permits a provider who is actively treating an enrollee to act as their representative for purposes of filing an appeal or grievance without requiring prior authorization from the enrollee. The provider, however, must furnish the enrollee with notice of such at least 14 days prior to filing the appeal or grievance and within 7 days after filing, and the enrollee may affirmatively object to such representation.

This new law requires carriers to allow prior authorizations to be effective for 14 days before or after the approved date if the service cannot be delivered on the approved date. For non-emergency services, the new law prohibits carriers from denying claims for those services so long as they were within the scope of the enrollee’s coverage pending medical necessity review. Carriers may also not impose a penalty on the provider for failing to obtain a prior authorization of greater than 15% of the contractually allowed amount for the services that required prior authorization approval.

This new law prohibits carriers from requiring prior authorization for post-evaluation or post-stabilization services provided during the same encounter. If post-evaluation or post-stabilization services require inpatient care, then the carrier may require prior authorization but it must respond to the prior authorization request within 24 hours. If the provider does not receive a determination within that 24-hour period, then the care is deemed approved until the carrier notifies the provider otherwise.

Lastly, this new law imposes new reporting requirements on carriers relating to prior authorization determinations, which will be collected by the Bureau of Insurance and reported to the Maine Legislature in 2025.