Each year, tens of thousands of people enrolled in private Medicare Advantage plans are denied necessary care that should be covered by the program, federal investigators concluded in a report released Thursday.
Investigators urged Medicare officials to step up oversight of these private insurance plans, which provide benefits to 28 million older Americans, and called for increased enforcement of plans with an inappropriate denial pattern.
Advantage plans have become an increasingly popular option among older Americans, offering privatized versions of Medicare that are often cheaper and offer a wider range of benefits than traditional government-run program offerings.
Enrollment in Advantage plans has more than doubled over the past decade, and half of Medicare beneficiaries are expected to choose a private insurer over the traditional government program in the next few years.
The industry’s leading trade group says people choose Medicare Advantage because “it provides better services, better access to care, and better value.” But federal investigators say there is disturbing evidence that the plans are delaying or even preventing Medicare beneficiaries from getting medically necessary care.
The new report, from the Office of the Inspector General of the Department of Health and Human Services, examined whether some of the rejected services would likely have been approved if recipients had been enrolled in traditional health insurance.
Tens of millions of denials are issued each year for authorization and reimbursements, and audits of private insurers show evidence of “widespread and persistent problems with inappropriate service and payment denials”, the investigators found.
The report echoes similar findings from the bureau in 2018, showing that private plans were reversing around three-quarters of their denials on appeal. Hospitals and doctors have long complained about insurance company tactics, and Congress is considering legislation to address some of those concerns.
In its review of 430 denials in June 2019, the inspector general’s office said it found repeated examples of denial of care for medical services that coding experts and physicians reviewing determined cases were medically necessary and should be Covered.
Based on its findings that about 13% of denied claims should have been covered by Medicare, investigators estimated that as many as 85,000 recipient claims for prior authorization for medical care were potentially wrongly denied in 2019.
Advantage plans also refused to pay legitimate claims, according to the report. About 18% of payments were declined despite following Medicare coverage rules, or about 1.5 million payments for all of 2019. In some cases, plans ignored prior authorizations or other necessary documentation to justify the payment.
These denials can delay or even prevent a Medicare Advantage beneficiary from getting needed care, said Rosemary Bartholomew, who led the team that worked on the report. Only a tiny fraction of patients or providers attempt to appeal such decisions, she said.
“We are also concerned that recipients may not be aware of larger barriers,” she said.
Kurt Pauker, an 87-year-old Holocaust survivor in Indianapolis who has kidney and heart problems that complicate his care, is enrolled in a Medicare Advantage plan sold by Humana.
Despite recommendations from Mr Pauker’s doctors, his family said, Humana repeatedly refused permission for hospital rehabilitation after hospitalization, saying he was sometimes too healthy and sometimes too sick to benefit. .
Last March, after undergoing hip surgery, Mr Pauker was again told he was not eligible for inpatient rehab but would be referred to a skilled nursing facility to recover , said his family.
During his previous stay at a skilled nursing facility, he received little physical or occupational therapy, the family said. He has so far lost his appeals and his relatives have chosen to pay for the care privately while continuing to pursue his case.
People “should know what they’re giving up,” said David B. Honig, a health care attorney and Mr. Pauker’s son-in-law. People who enroll in Medicare Advantage waive their right to have a doctor determine what is medically necessary, he said, rather than let the insurer decide.
Humana, which reported strong earnings on Wednesday, said it could not comment specifically on Mr. Pauker’s case, citing confidentiality rules. But the insurer noted that it was required to follow standards set by the Centers for Medicare and Medicaid Services.
“While each member’s experience and needs are unique, we strive to provide health coverage that matches what we believe CMS would require in each case and helps our members achieve their best health,” Humana said. in a press release.
Medicare officials said in a statement they are reviewing the findings to determine appropriate next steps, and that plans with repeated violations will face escalating penalties.
The agency “is committed to ensuring that people on Medicare Advantage have timely access to medically necessary care,” officials said.
The federal government pays private insurers a fixed amount per Medicare Advantage patient. If the patient’s choice of hospital or doctor is limited and they are encouraged to obtain less expensive but effective services, the insurer has everything to gain.
Under traditional health insurance, hospitals and doctors may have an incentive to overtreat patients because they are paid for every service and test performed. But the fixed payment granted to private plans provides “the potential incentive for insurers to deny access to services and payment in an effort to increase their profits,” the report concludes.
Dr. Jack Resneck Jr., president-elect of the American Medical Association, said denials of the plans had become widespread. The organization has lobbied lawmakers to impose stricter rules.
Prior authorization, intended to limit very expensive or unproven treatments, has “expanded far beyond its original purpose,” Dr. Resneck said. When patients can’t get approval for a new prescription, many don’t fill it and never tell the doctor, he added.
Calls end up unfairly burdening patients and often taking up valuable time, some doctors have said.
“We are able to reverse that from time to time,” said Dr. Kashyap Patel, a cancer specialist who is chief executive of Carolina Blood and Cancer Care and chair of the Community Oncology Alliance. But his efforts to “fight like a hawk” to get approvals for the care he recommends also leaves him with less time to care for patients, he added.
The most common refusals found by investigators included those for imaging services like MRIs and CT scans. In one case, an Advantage plan refused to approve a follow-up MRI to determine if a lesion was malignant after it was identified by a previous CT scan because the lesion was too small. The regime reversed its decision after an appeal.
In another case, a patient had to wait five weeks before getting a CT scan to assess her endometrial cancer and determine a treatment. Such delayed care can negatively affect a patient’s health, the report notes.
But Advantage plans have also refused requests to send patients recovering from a hospital stay to a skilled nursing facility or rehabilitation center when doctors determined those places were more appropriate than sending them away. a patient at home.
A patient with pressure sores and a bacterial skin infection was refused transfer to a skilled nursing facility, investigators have found. A high-risk patient recovering from surgery to repair a fractured femur has been refused admission to a rehabilitation center, despite doctors saying the patient must be under the supervision of a doctor .
In some cases, investigators said Medicare rules — like whether a plan can require a patient to have an X-ray before having an MRI — needed to be clarified.
Plans can use their own clinical criteria to judge whether a test or service should be reimbursed, but they must offer the same benefits as traditional health insurance and cannot be more restrictive in paying for care.
Investigators urged Medicare officials to strengthen oversight of Advantage plans and provide consumers with “clear and easily accessible information about serious violations.”