Q&A: Understanding utilization review requirements for Medicare Advantage

Q: Where can I find information on utilization review (UR) requirements for Medicare Advantage (MA)?

A: CMS’ Medicare Managed Care Manual is a separate policy manual for MA plans. The manual delineates all of the compliance, coverage, and payment regulations along with required beneficiary protections. CMS specifies that MA plan enrollees must have access to benefits that are equal to or better than traditional Medicare by the plans furnishing the services directly, through arrangement, or paying on behalf of the enrollee.

Although the scope of benefits is clearly delineated in the Medicare Managed Care Manual, CMS considers the payment and UR processes from the MA plan to the provider to be a contractual issue and does not regulate them. As a result, many MA plans have implemented precertification requirements, established proprietary level-of-care stratification tools, and hired independent organizations to perform audits of inpatient admissions in a manner similar to that of a Recovery Audit Contractor—not to deprive beneficiaries of needed care but rather to avoid paying providers for that care.

For more information see Hospital Guide to Contemporary Utilization Review, Second Edition.