One thing’s for sure. If there’s a way for the UnitedHealth, Humana and CVS/Aetna to profit off of Medicare Advantage, they will find it. We know that they overcharge the government more than $2,300 a year per enrollee. A new Senate Permanent Committee on Investigations report finds that Medicare Advantage insurers also profit from denying rehab services, nursing services and other costly services at ever-increasing rates.
The Senate Permanent Subcommittee on Investigations’ report warns that insurers “are using prior authorization to protect billions in profits while forcing vulnerable patients into impossible choices.” Older adults and people with disabilities are getting hurt. What exactly are the insurers doing to manage their enrollees’ care?
According to Senator Richard Blumenthal, who chairs the Subcommittee: “Insurance companies say that prior authorization is meant to prevent unnecessary medical services. But the Permanent Subcommittee on Investigations has obtained new data and internal documents from the largest Medicare Advantage insurers that discredit these contentions. In fact, despite alarm and criticism in recent years about abuses and excesses, insurers have continued to deny care to vulnerable seniors—simply to make more money. Our Subcommittee even found evidence of insurers expanding this practice in recent years.”
How do the insurers get away with all these denials? The report does not explain how the insurers get away with all these denials. But, the answer is simple. They often deploy a proprietary “secret sauce” to determine whether they should cover costly care. Their sauce can take a very narrow view of what is medically necessary care. Consequently, amputees can be denied rehab services. Newly diagnosed leukemia patients can be forced to wait long periods before their urgently needed care is approved.
Is there evidence that insurers are not using prior authorization to improve care? All we hear is that they use prior authorization to keep people from getting care and to increase their profits. The Senate report does not get into other findings that some prior authorization denials for costly services are overturned on appeal more than 75 percent of the time. But, most people don’t appeal their coverage denials. The vast majority end up going without needed care. No one is looking out for them.
The Centers for Medicare and Medicaid Services does not begin to have the resources to oversee nearly 4,000 different Medicare Advantage plans. It also lacks the power to hold insurers to account for their bad acts in meaningful ways.
How to fix prior authorization? More rules won’t fix prior authorization in Medicare Advantage. Congress needs to take prior authorization out of the hands of the profit-driven insurers and put it into the hands of an outside independent entity that applies medically sound prior authorization rules in a standardized way across all Medicare Advantage plans.
Here’s more from Just Care:
- Issues with network adequacy and prior authorization in Medicare Advantage persist
- Bill in Congress to address burdensome Medicare Advantage prior authorization requirements will be of little help
- OIG finds widespread inappropriate care denials in Medicare Advantage
- 2024: What to know this Medicare Open Enrollment Period
- Louisiana: Medicare Advantage denials harm patients, while gouging taxpayers
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