In a letter to the CMS Administrator, Senators Elizabeth Warren, Catherine Cortez-Masto, Bill Cassidy and Marsha Blackburn call for better Medicare Advantage data collection and reporting. Lack of good Medicare Advantage data prevents the Centers for Medicare and Medicaid Services (CMS) from effectively overseeing and reforming the Medicare Advantage program and make it impossible for people with Medicare to make a meaningful choice of a Medicare Advantage plan, let alone protect themselves from the bad actor Medicare Advantage plans.
“[I]n the last few years, federal watchdogs have released numerous reports examining concerning trends in MA… These findings raise important questions about ensuring the integrity and fiscal sustainability of the Medicare Advantage program. Without publicly available plan-level data on prior authorization requests by type of service, timeliness of determinations and reasons for denials; claims and payment requests denied after a service has been provided; beneficiary out-of-pocket spending; and disenrollment patterns, policymakers and regulators are unable to adequately oversee the program and legislate potential reforms,” wrote the senators.
The Senators have it almost right. All this data is needed. Unfortunately, even if it were realistic to expect that the MA plans would release data of this nature, the data they do release is never complete, accurate or timely, reports the Medicare Payment Advisory Commission. Moreover, because each MA plan is permitted to handle the prior authorization process differently, using proprietary tools, it is impossible for the Centers for Medicare and Medicaid Services to oversee the MA plans effectively. Without a lot more standardization of claims processing in MA plans, the MA plans are free to engage in bad acts, such as denying claims inappropriately, with little chance they will be caught, let alone held to account.
In sum, people do not have the information they need to choose among Medicare Advantage plans. MA plans have failed to turn over complete and accurate patient encounter data for years, with impunity. Without this data, it is not possible to assess quality of care in Medicare Advantage and how well an MA plan performs, as the Medicare Payment Advisory Commission (MedPAC) has said repeatedly.
The most important question to ask yourself if you’re in a Medicare Advantage plan or thinking of joining one is: Will I get the care I need when I most need care–be it hospital care, rehab services, cancer treatment, nursing or home care. Do not assume you or your loved ones will. Unfortunately, in Medicare Advantage, there’s no telling. Some Medicare Advantage plans deny high levels of medically necessary care or delay care to the serious detriment of their enrollees. The data is missing to tell you which ones to avoid. And, the government cannot protect you from the bad actors.
The Senators’ letter to the CMS Administrator explains that the Office of the Inspector General has found widespread inappropriate Medicare Advantage prior authorization denials and payment denials. And, the General Accounting Office has found that people who are in the last year of life are twice as likely to disenroll from a Medicare Advantage plan and switch to traditional Medicare. Most people are locked into a Medicare Advantage plan once they join because the supplemental coverage people need to protect themselves financially in traditional Medicare, which lacks an out-of-pocket cap, tends to be unavailable or unaffordable.
In their letter. the Senators also note that overpayments to Medicare Advantage plans need fixing. These overpayments have been estimated to be as high as $140 billion this year alone. They are eating into the Medicare Trust Fund and driving up Part B premiums for everyone, significantly. The Committee for a Responsible Federal Budget projects as much as $250 Billion in additional Part B premiums over the next ten years if the overpayments are not corrected.
In addition to complete encounter data, the Senators are urging CMS to collect and report the following:
- Prior authorization requests, denials, and appeals by type of service. Among other things, collecting this data would permit assessment of whether MA plans are covering all Medicare Part A and Part B services, as required.
- Justification of prior authorization denials. With this information, CMS could better determine whether denials are appropriate.
- Timeliness of prior authorization decisions.
- Utilization of supplemental benefits and associated out-of-pocket costs. Right now, it is not clear who is using these benefits or what they are paying. With this information, CMS could determine whether they have real value.
CMS collects other data that the Senators want CMS to publicly report, including:
- Out-of-pocket costs and provider payment information.
- Disenrollment data broken down into subgroups. This information would help the public understand whether people are leaving MA because of the cost of care or the inability to get needed care.
- Plan comparison information in MA and TM, including health outcomes.
Here’s more from Just Care:
- Medicare Advantage plans denied two million prior authorization requests in 2021
- CMS can’t oversee AI denials in Medicare Advantage
- Be a Hero tells Congress to end Medicare Advantage wrongful delays and denials of care
- What we don’t know about Medicare Advantage plans
- Older adults in US face high cost-related barriers to care
Leave a Reply