The public has now heard from the American Medical Association, the American Hospital Association and the HHS Office of the Inspector General that some Medicare Advantage plans undermine access to needed care and could cause enrollees serious harm or even death. The trade association for the corporate health plans now supports a bill in Congress that claims to address problems with prior authorization, reports Kelsey Waddill for HealthPayerIntelligence. But, the bill does not go nearly far enough to improve access to care and protect the lives and well-being of people in Medicare Advantage.
The sponsors of HR 3173, the Improving Seniors’ Timely Access to Care Act, say it would streamline prior authorization in Medicare Advantage and make more prior authorization data available. It would put in place an electronic process for securing prior authorization and “encourage an industry standard” with regard to prior authorization. That’s a good step, but not nearly enough.
Streamlining the prior authorization process is only as good as the prior authorization rules in place. If the rules are out of sync with standard medical practice–as the American Medical Association claims some are–streamlining the process won’t help. People will still be denied medically necessary care.
The Office of the Inspector General found that more than one in eight Medicare Advantage plan denials were made in error. Changing procedural rules won’t fix this egregious problem. Thirteen percent of the services that Medicare Advantage plans are denying are covered for people in traditional Medicare.
Physicians say that prior authorization both affects patient health outcomes and undermines continuity of care for patients. Medicare Advantage’s use of prior authorization rules can lead to poor health outcomes for their enrollees.
The bi-partisan bill in Congress requiring Medicare Advantage reporting of approval and denial rates of services needing prior authorizations doesn’t address the potentially serious consequences of prior authorization for Medicare Advantage enrollees. The sentinel question is “Are the prior authorization rules reasonable and in sync with standard medical practice?” Yet, it appears that the bill, as written, permits Medicare Advantage plans to continue to keep these rules proprietary, unavailable for public scrutiny; they are simply “encouraged” to work with provider groups to ensure the rules are in sync with standard medical practice.
Keep in mind that Medicare Advantage plans also often make it impossible for enrollees to see top quality providers, be they specialist physicians or specialty hospitals. These providers are often out-of-network and therefore unaffordable. Moreover, bureaucratic hoops seeing in-network providers as well as out-of-pocket costs can create barriers to care, especially for the most vulnerable people with Medicare.
Here’s more from Just Care:
- Four things to think about when choosing between traditional Medicare and Medicare Advantage plans
- Well-kept secrets of Medicare Advantage plans
- How prior authorization requirements in Medicare Advantage could threaten your health
- AHA underscores dangers of Medicare Advantage, need for greater accountability
- OIG finds widespread inappropriate care denials in Medicare Advantage
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