Recently, the HHS Office of the Inspector General (OIG) issued a report finding widespread, inappropriate delays and denials of care in Medicare Advantage. Picking up on those findings, the American Hospital Association (AHA) has now sent a letter to the Centers for Medicare and Medicaid Services (CMS) urging it to better oversee Medicare Advantage plans to prevent serious harm to patients and to hold Medicare Advantage plans accountable for their bad acts. Separately, the AHA called on the Justice Department to conduct additional False Claims Act investigations of Medicare Advantage plans for inappropriately denying people care and providers payment.
The AHA highlights a range of concerns with Medicare Advantage. It calls for CMS collection and public reporting of data on delays and denials of care as well as grievances and appeals at the plan-level. This information is critical. People need to know whether their Medicare Advantage plan is putting enrollees’ health and well-being at risk.
The AHA also recommends that CMS not pay Medicare Advantage plans in a way that incentivizes them to deny care. It stops short of saying that CMS should stop paying them a capitated fee that bears no relation to the cost of services they cover. But, that’s what needs to happen.
Right now, Medicare Advantage plans can profit handsomely from denying care. Consequently, they have every reason to avoid including high quality specialists and specialty hospitals in their networks; and, they deter people with costly conditions from enrolling in their plans; they also discourage enrollees with costly conditions from remaining in their plans.
The AHA does not suggest that CMS cancel its contracts with Medicare Advantage plans that are systematically violating their contractual obligations. That is the best way to protect people with Medicare. CMS should eliminate the bad Medicare Advantage actors so people cannot enroll in them.
Still, the AHA explains that some Medicare Advantage plans are not complying with standard medical practice when they deny coverage for certain services. These plans are required to apply the same coverage criteria as traditional Medicare. But, they use more restrictive criteria that can endanger the lives of their enrollees. They deny coverage for care that traditional Medicare pays for.
Moreover, the AHA highlights how the prior authorization protocols of some plans require much time and resources, driving up the cost of care. They create delays for patients in accessing needed care, often to the detriment of their health. These processes should be streamlined and uniform for all plans.
In its pitch to the Justice Department, the AHA asked the Justice Department to create a task force for Medicare Advantage investigations. The government should impose civil and criminal penalties on Medicare Advantage plans that wrongly deny enrollees care and deny payment to providers for medically needed care. In their view, these penalties would prevent fraud.
Here’s more from Just Care:
- Prior authorization in Medicare Advantage harms patients, sometimes severely
- OIG finds widespread inappropriate care denials in Medicare Advantage
- MedPAC blasts Medicare Advantage
- One in four Medicare Advantage plans engage in misleading marketing
- Four things to think about when choosing between traditional Medicare and Medicare Advantage plans
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