Letter to CMS regarding Part C IRE CommunicationsOctober 5, 2026 The Honorable Mehmet Oz, M.D. Re: Strengthening the Independence, Transparency, and Accessibility of the Medicare Advantage Part C Independent Review Process Dear Administrator Oz: On behalf of the members of the American College of Physician Advisors (ACPA), we respectfully request that CMS take prompt action to strengthen the Medicare Advantage Part C Independent Review Entity (IRE) process. Our members routinely advocate for Medicare Advantage (MA) enrollees during pre-service and concurrent coverage appeals and, when an MA organization (MAO) upholds a denial, frequently assist beneficiaries through the subsequent Part C IRE review process. We recognize and support the important role of the Part C IRE in providing an independent review of adverse Medicare Advantage coverage determinations. However, ACPA members have encountered structural communication barriers that can make it extraordinarily difficult for providers, beneficiaries, and authorized representatives to participate meaningfully in the IRE process. An independent review is only fully protective of beneficiary rights when the beneficiary and those assisting them have a practical ability to know that the review is occurring, participate in it, provide relevant information, and obtain the resulting determination. Based on the experiences reported by ACPA members, several aspects of the current Part C IRE process present significant barriers to meaningful participation. 1. Lack of timely notification when a case reaches the Part C IREProviders advocating on behalf of MA enrollees generally do not know when an MAO forwards an appeal to the Part C IRE. In addition, providers may not know whether the case is being reviewed under the expedited or standard appeal timeframe. This creates a significant practical problem. Without knowing when the IRE receives the case or which timeframe applies, an assisting provider cannot reliably determine when additional information must be submitted or when a determination should be expected. For pre-service and concurrent appeals in particular, these are not merely administrative concerns. The care at issue may be ongoing, and the timing of the review can directly affect the beneficiary’s access to medically necessary care. 2. Limited opportunity to review or supplement the IRE case fileProviders frequently do not have a meaningful opportunity to review or supplement the case file transmitted by the MAO to the Part C IRE because they do not know when the IRE receives the case. The MAO’s record may not contain all of the information available to the treating or reviewing provider. Clinical circumstances can also change rapidly during an ongoing hospitalization or treatment episode. A process that permits the MAO to transmit the record to the IRE without providing the beneficiary or the beneficiary’s representative with a reliable mechanism to know that the review has commenced and to supplement the record can inadvertently make the IRE’s review dependent upon an incomplete record. 3. Problems receiving the Medicare Appeals System Case IDACPA members understand that the Part C IRE sends an acknowledgment letter to the beneficiary and provider that includes the Medicare Appeals System (MAS) Case ID. However, members report that providers rarely receive these letters. Providers report calling the plan to obtain the number but are often unsuccessful in doing so. One apparent contributing factor may be the use of the provider address supplied by the MAO, without a mechanism for the provider to directly identify and communicate with the appropriate department, individual, electronic address, or other destination for IRE correspondence. The MAS Case ID is particularly important because, without it, providers cannot readily look up the status or outcome of an appeal through available online resources. 4. Providers may not receive Part C IRE decision lettersACPA members also report that providers do not consistently receive the Part C IRE’s final decision letters. This can have significant consequences for beneficiary appeal rights. When an IRE upholds an adverse determination, the beneficiary may have additional appeal rights, including the opportunity to request an Administrative Law Judge (ALJ) hearing when the applicable requirements are satisfied. If the provider assisting the beneficiary does not receive the IRE decision and cannot obtain it electronically or by fax, the provider may be unable to effectively assist the beneficiary in exercising those rights. ACPA members have experienced circumstances in which the inability to obtain the IRE decision letter has effectively prevented a timely ALJ hearing request from being filed. This is particularly concerning because the inability to obtain the decision is not a substantive determination that the beneficiary lacks an appeal right; rather, it is an administrative barrier to exercising that right. 5. Telephone-only communication is inadequate for time-sensitive appealsThe Part C IRE currently provides a telephone pathway for provider communication. ACPA members report that calls generally proceed to voicemail with a promise of a return call within 24 business hours. While a callback mechanism is useful, it is not an adequate substitute for direct, synchronous communication in urgent medical cases. Members report that callbacks do not always occur within the expected timeframe, and sometimes do not occur at all, resulting in repeated telephone calls and “telephone tag.” In a time-sensitive pre-service or concurrent appeal, this can consume critical time and make meaningful communication between the treating provider and IRE difficult. 6. Lack of an electronic communication pathway for providersACPA members report that the Part C IRE does not provide a dedicated email address for case inquiries or an electronic portal through which providers can monitor an appeal. One member reported that, after weeks of attempting to communicate via telephone, an email exchange was initiated but subsequently discontinued because the email address was reportedly intended only for communications with MAOs and not with providers. The provider was instructed to continue using the telephone pathway. A modern Medicare appeals system should not require beneficiaries and the professionals assisting them to rely almost exclusively on postal mail and voicemail to communicate about active, time-sensitive appeals. The result: an independent review that can be difficult to access and participate inTaken together, these structural barriers can undermine the practical effectiveness of the Part C IRE process. ACPA fully supports independent review. Indeed, physician advisors routinely seek independent review because it provides an important safeguard for Medicare Advantage beneficiaries and helps ensure that coverage decisions are evaluated objectively. However, independence of adjudication and accessibility of the process are complementary—not competing—principles. A beneficiary’s right to an independent review is of limited practical value if the beneficiary and the provider assisting the beneficiary cannot reliably determine:
These are especially important considerations for pre-service and concurrent appeals, where delays can affect ongoing treatment and where clinical information may evolve during the review process. ACPA’s recommendationsWe respectfully ask that CMS work expeditiously with the Part C IRE to establish modern, secure communication pathways for Medicare Advantage beneficiaries, their representatives, and providers assisting them. Specifically, we recommend that CMS require implementation of the following: 1. A dedicated electronic communication channel. Establish a secure email or comparable electronic communication pathway through which a beneficiary, authorized representative, or assisting provider may submit inquiries concerning an active Part C IRE appeal and receive a meaningful response within 24 hours, with appropriate safeguards for protected health information. 2. Provider access to the Medicare Appeals System Case ID and appeal status. Establish a secure portal through which an assisting provider, with appropriate authorization, can identify an appeal using the beneficiary’s Medicare Beneficiary Identifier (MBI) and obtain the associated MAS Case ID and current appeal status. 3. Electronic access to the IRE case record. Provide a secure mechanism through which a beneficiary, authorized representative, or assisting provider can review information relevant to the appeal and, where appropriate, submit additional documentation or clinical information for consideration by the IRE. 4. Real-time status information. Allow authorized beneficiaries, representatives, and assisting providers to determine whether an appeal has been received by the IRE, whether it is being processed under expedited or standard timeframes, whether review is pending or complete, and whether a determination has been issued. 5. Electronic access to IRE determinations. Make IRE decision letters available electronically through the secure portal, in addition to any required postal notification. Authorized providers assisting beneficiaries should be able to obtain the decision promptly when the beneficiary has authorized the provider’s involvement. 6. Reliable notification of IRE receipt and decisions. Allow beneficiaries and their authorized representatives to designate appropriate contact information—including a provider department, utilization management department, physician advisor, or other authorized representative—for electronic notification of IRE receipt and determination. These enhancements would not diminish the independence of the IRE. To the contrary, they would strengthen the integrity of the independent review process by ensuring that the reviewer has access to a more complete record and that beneficiaries have a practical opportunity to exercise their rights. ConclusionACPA members appreciate the importance of CMS’s efforts to protect Medicare Advantage beneficiaries and to ensure that MA organizations comply with federal requirements governing coverage and appeals. We also appreciate that, during your tenure at CMS, you have prioritized the development of secure and electronic means of communication and information transfer. We respectfully ask that similar modernization efforts be applied to communication among the Part C IRE, Medicare Advantage beneficiaries, their representatives, and the providers who care for them. The goal is straightforward: a beneficiary who has been denied coverage should not lose the practical ability to pursue an independent review or a subsequent appeal simply because the beneficiary or the professional assisting them cannot obtain timely information about the status or outcome of the IRE review. A secure electronic portal, reliable electronic notifications, meaningful provider communication, and prompt electronic access to case information and decisions would substantially improve transparency, reduce administrative burden, and—most importantly—better protect the appeal rights of Medicare Advantage beneficiaries. We respectfully request that CMS evaluate these concerns and work expeditiously with the Part C IRE to implement these communication enhancements. Thank you for your consideration and for your continued work on behalf of Medicare beneficiaries. Respectfully, Ahmed Abuabdou, MBBS, MBA, ACPA-C |