| |  | The Lead Brief | Insurers looking for guidance on how regulators plan to approach Medicare Advantage rules watched CMS Administrator Mehmet Oz appear at an industry conference with Marvin Gaye’s “I Heard It Through the Grapevine” playing in the background. Oz, a physician who had his own television show, worked the crowd at the Better Medicare Alliance’s policy summit on Wednesday. He came close to scolding the industry — hinting that Medicare Advantage plans should do a better job at controlling costs — but emphasized wanting to work with them. “I’m here today because we’re open for business, and we want to hear your ideas,” he said. “But then also, take action on your own when possible. We’ll give you safe harbor. We’ll support you. We’ll do things that are necessary to make it easier for you to do the right thing.” Here are some key takeaways from his talk: — “UPCODING” AND IN-HOME RISK ASSESSMENTS In a Q&A, Better Medicare Alliance CEO Mary Beth Donahue asked Oz about the controversial topic of in-home health assessments that can determine how much plans get paid for coverage — and the audience may have gotten slightly more than they bargained for. → Some insurers have been accused by a government watchdog of using these assessments to tack on additional diagnosis codes to get reimbursed more for those patients. “I built my career on preventive health, I’m strongly supportive of home visits. What I’m not supportive of is coding problems that don’t get treated or aren’t a focus of treatment,” Oz replied, noting that adding diagnosis codes rarely predicts what treatment a patient will need. “If we think that there's an additional benefit of coding, then you professionalize coding — you build systems that are designed to increase coding when it doesn't really translate any changes in care,” he added. “We should pay you more for taking better care of someone who has more complicated problems, but I shouldn't rely on some third-party group to help figure that out for me,” he said, referencing the firms some insurers will hire to do the reviews. → Following that line, there was nervous laughter followed by a few claps from the audience. Oz expressed shock that industry leaders wouldn’t be used to hearing the criticism. “When I say things that sound like they might be harsher, folks who are industry leaders like it because they're doing those things anyway,” he said. “They just get pulled, dragged behind by folks who are getting away with not doing the job the best it can be done. We’ve tolerated it for too long.” — SKIN SUBSTITUTES SPENDING Oz gave a glimpse into whether CMS may finalize its proposal to cap Medicare reimbursement for expensive bandages, known as skin substitutes. In 2024, Medicare spent about $10 billion on the wound dressings — an amount that has increasingly skyrocketed over the years, according to a federal government watchdog. The health care industry — including manufacturers, providers and insurance plans — are waiting to see whether CMS follows through with the proposal to limit payments to $125 per square centimeter. → On Wednesday, Oz lamented that reimbursements for skin substitutes will likely cost the government more than $13 billion this year — a 30 percent increase over last year. “It’s very hard to justify that increased expense by outcomes — which really haven’t been reported in ways that are at least discernible from the [Food and Drug Administration] perspective — as being a better quality experience, and we can’t tell either,” he said. “We’re starting to think, if this had been policed earlier, could we have prevented this? And what are these guys going to do next? Because they’re not going to go away.” “We've allowed bad players to come into a sector,” he said, “and unless you drive them all out, they will just find other ways of eating the fruit of the harvest, and we are going to do that in this administration.” — ADDRESSING PRIOR AUTHORIZATION Requiring prior authorizations for some procedures is a way that insurers try to keep costs down. Earlier this year, the Trump administration secured pledges from insurers to speed up the prior authorization process — aiming to combat complaints from doctors and patients that it creates barriers to care. “We have regulatory powers to obviously play a role in how things are done, but maybe, if you want to be fast and effective and more nimble, you'll use industry and have them do it,” Oz told the audience, using it as an example of ways to lean on the industry instead of imposing regulations. However, he reminded them: “We’re here watching, and we have the ability to take action when necessary.” → He mentioned that some plans have “gold cards” for some providers they trust that allow them to bypass the prior authorization process all together — encouraging more insurers to adopt the practice. | 
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