Last week, 294 members of Congress sent a letter to Secretary of Health and Human Services, Xavier Becerra and the Centers for Medicare and Medicaid Services (CMS) seeking greater protections for people in Medicare Advantage plans. The letter focuses on the need to speed up the prior authorization process in Medicare Advantage and alludes to the risk to Medicare Advantage enrollees from delays and denials of care. Congress wants the Centers for Medicare and Medicaid Services to help ensure that people in Medicare Advantage get timely access to care, which people cannot count on today.
CMS has proposed a rule that is designed to help ensure people in Medicare Advantage are not waiting to get the care they need. But, a bipartisan majority of members of Congress correctly appreciate that the rule does not go far enough. They want to help ensure that the Medicare Advantage plans use an electronic prior authorization system and that they are transparent about what they are doing. They know full well that right now, people in some Medicare Advantage plans are dying or being harmed needlessly because their Medicare Advantage plans are not providing them the care they need when they need it.
The problem, as many see it, is that the government pays the Medicare Advantage plans upfront for their services, with too little regard as to whether the Medicare Advantage plans are providing their enrollees with the Medicare benefits they are due. The Medicare Advantage plans have a powerful incentive to delay and deny care in order to maximize profits. CMS does not have the resources to undertake annual audits of these plans to ensure they are complying with their contractual obligations. And, CMS does not have the political will to penalize them appropriately for their bad acts when it uncovers them.
People in Medicare Advantage plans cannot even know whether their Medicare Advantage plans are engaged in widespread inappropriate delays and denials of care, as some of them are, according to the HHS Office of the Inspector General. The letter from members of Congress requests that CMS go further than it has in its proposed rules to improve the prior authorization process and ensure a “real time process for items and services that are routinely approved.” It also seeks a 24-hour prior authorization turnaround time for urgently needed care, recognizing that delays could “jeopardize a patient’s life, health or ability to regain maximum function.”
Here’s more from Just Care:
- OIG finds widespread inappropriate care denials in Medicare Advantage
- How prior authorization requirements in Medicare Advantage could threaten your health
- Medicare Advantage ads will continue to mislead despite new rules
- Medicare Advantage plans use AI to deny care
- Case study: Medicare Advantage delays, denials and consequences
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