In the recent turn of events, bodies including Department of Health and Human Services (“HHS”), Office of the Inspector General (“OIG”), HHS’s Centers for Medicare & Medicaid Services (“CMS”), and Congress have shifted their focus on the role of managed care in the Medicare and Medicaid programs. This shift appears to have initiated a crescendo of oversight of Medicare Advantage and Medicaid Managed Care.
A detailed evaluation of this situation can be found in the document by the OIG titled ‘Strategic Plan: Oversight of Managed Care for Medicare and Medicaid’ which was published in August 2023. One of the key elements under scrutiny in the strategic plan by OIG, CMS, and Congress is the way managed care organizations use prior authorization. This component can often create significant barriers for beneficiaries to obtain necessary care and services.
Alongside the plan, Congress has shown increased interest in the managed care space, which becomes evident from its query and subsequent report detailing how the managed care organizations have spent the billions of dollars they have received over the COVID-19 public health emergency.
This growing oversight and scrutiny from key regulatory and legislative bodies indicate a dynamic shift in healthcare policy. It signals an escalating attempt to ensure that Medicare Advantage and Medicaid Managed Care organizations operate in a manner that ensures the best outcomes fir their beneficiaries.
The legal community, especially those advising the healthcare sector, should pay close attention to this development. The unfolding landscape could present both challenges and opportunities as new norms and regulations are ushered in.
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