MedPAC, the Medicare Payment Advisory Commission, just released a report focused in part on Medicare Advantage network adequacy and prior authorization issues. People enrolled in Medicare Advantage plans can find it challenging both to find health care providers who meet their health care needs and to get covered for the care their treating physician says they need. The Centers for Medicare and Medicaid Services (CMS) has taken some steps to address these issues, but there’s more to be done.
Many hospitals and physician specialists say that some Medicare Advantage plans endanger patient health and well-being as a result of inadequate networks and non-evidence-based prior authorization requirements. In particular, many Medicare Advantage do not have cancer centers of excellence or mental health specialits in their networks. And, CMS only studies network adequacy at the “contract” level, meaning that it looks at an insurers’ entire network in an area, not at the networks of each individual Medicare Advantage plan the insurer offers.
MedPAC explains in its report that in 2021, MA plans required prior authorization in 37.5 million instance, about 1.5 determinations for each enrollee. In the vast majority of cases, the MA plan covered the service. MedPAC does not address the consequences of delays in getting these determinations on patient health.
In nearly two million cases–about five percent of the time–the MA plan denied coverage for the service requested. But, different MA plans had very different denial rates. Some denied coverage three percent of the time and some 12 percent of the time. Unfortunately, as of now, no one know which are denying 12 percent and which are denying 3 percent of requests, preventing individuals from distinguishing meaningfully among Medicare Advantage plans.
The insurers offering Medicare Advantage profit significantly from denials. Most of the time, they are not appealed. Only 11 percent of denials are appealed, even though 80 percent of the time they are reversed on appeal.
For sure, prior authorization costs hospitals and physicians a lot of time and money. To what extent is it keeping patients from getting necessary care or delaying critical care or creating a serious health risk?
Even a small proportion of prior authorization denials amounts to a large number of denials. The vast majority are not challenged, often to the detriment of patients. The Office of Inspector General’s audits suggests that a large proportion of those denials should have been approved.
Here’s more from Just Care:
- If Medicare Advantage can’t offer adequate provider networks and accurate directories, why are they in business?
- Out-of-network care: Don’t trust your insurer to pay the bills
- If you’re in a Medicare Advantage plan, watch out! Your doctor or hospital might no longer be in-network
- What to do if your in-network doctor goes out of network?
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