In a letter to the Medicare Payment Advisory Commission (MedPAC), the American Hospital Association (AHA) expresses serious concerns about the dangers of Medicare Advantage, including the consequences of inappropriate coverage and payment denials and delays. MA is not delivering the health coverage people need; and, prior authorization requirements delay potentially life-saving time-sensitive treatments, such as cancer treatment regimens.
The AHA explains that the insurers offering Medicare Advantage plans use prior authorization in ways that create “dangerous delays in care.” The AHA’s greatest concern is that MA plans use prior authorization to deny medically necessary care. To show clinical appropriateness, providers are required to spend an excessive amount of resources documenting the need, while patients’ care is delayed, to their detriment.
The stories the AHA recounts of insurer MA bad acts are disturbing, appearing to put insurers’ profits ahead of patient needs: “For example, an AHA member indicated that a patient with traumatic brain injury was medically ready for discharge but stayed four additional days in the hospital without access to essential [post-acute care] because the insurer had not responded to the provider’s request to move the patient into a rehabilitation facility. Another AHA member … reports that 11% of their MA referrals take 10 days or longer to resolve. Furthermore, another AHA member reported that, in 2022, over 400 MA patients at its academic medical center had delayed discharges due to insurance issues, the vast majority of which were attributable to prior authorization delays, and the delays amounted to 1,233 avoidable inpatient days.”
More than nine in 10 physicians report patient care delays because of prior authorization and one in three of them say that prior authorization resulted in a “serious adverse event for a patient in their care such as hospitalization or death.” Not only does the prior authorization process endanger the health and well-being of patients, it can be extremely burdensome for providers. Moreover, the process is not transparent or consistent across MA plans. Different rules for different plans and different electronic portals make it all the harder for providers to comply.
MedPAC is an independent Congressional agency established to advise Congress on the Medicare program. MedPAC can write reports on MA issues, but it has no real authority to do anything. And, neither Congress nor the Centers for Medicare and Medicaid Services seem to respond in meaningful ways to MedPAC recommendations.
Right now, the benefits of prior authorization appear more than outweighed by the harm to patients and the burdens on providers. That will continue so long as each insurer can develop its own proprietary prior authorization protocols. CMS should mandate that insurers all use one standardized set of public and medically justified prior authorization protocols and one standardized system for handling them. Without standardized and public prior authorization protocols, people cannot know whether the MA plan they enroll in will delay and deny their care excessively and inappropriately, as appears to be the case for people in UnitedHealth and Humana Medicare Advantage plans.
Here’s more from Just Care:
- AHA underscores dangers of Medicare Advantage, need for greater accountability
- Medicare Advantage: Denials and more denials, some deadly
- Corporate health insurers use NaviHealth algorithms to deny care in Medicare Advantage plans
- Medicare Advantage plans denied two million prior authorization requests in 2021
- Medicare Advantage poses grave risk to rehab facilities and nursing homes
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