Compliance with CMS 4201-F pie chart

Medicare Advantage Organization Non-Compliance with The Two-Midnight Rule Findings

AppriseMD hospital utilization review data for the first two months of 2024 shows that Medicare Advantage Organizations (MAOs) are denying claims that would have been approved under Traditional Medicare.

MAOs must adhere to the same guidelines as Traditional Medicare as per the Center for Medicare and Medicaid Services’ (CMS) 2024 rule 4201-F. MAOs can no longer be more restrictive than Traditional Medicare and must follow the Two-Midnight rule for all Medicare Advantage (MA) patients. Finally, MAOs are expected to use the same definitions as Traditional Medicare, no longer allowing commercial products to change coverage or payment criteria already established under Medicare law.


Compliance with CMS 4201-F pie chartAccording to AppriseMD’s data, the MAOs appear to be misapplying criteria and citing arbitrary findings to reach the conclusion that claims lack medical necessity. Data analysis of peer-to-peer (P2P) cases with MAOs covering the first two months of 2024 showed a 4201-F compliance rate of only 20%. The rest (80%) of the P2P cases that met 4201-F remain denied by the MAOs, highlighting just how severe the problem is.  AppriseMD physician advisors see non-compliance with CMS-4201-F occurring at both the initial level and during the appeal process when a hospital challenges an inpatient admission denial made by an MA plan.

One hospital CEO even blames the MA plans as the reason for having to cut staff.

“The Medicare Advantage abuse is outrageous,” Kurth Barwis, CEO of Bristol Health in Connecticut, stated in a Becker’s Healthcare article. Barwis shared that 63% of his Medicare patients are covered by MA plans, and MAOs have been “denying claims more frequently, and delaying payments for the claims they do approve.”

Read more in white paper: Medicare Advantage and the Two-Midnight Rule: 2024 Findings


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