JustCare

Tag: Denial

  • Low-income communities are particularly at risk in Medicare Advantage

    Low-income communities are particularly at risk in Medicare Advantage

    Insurers offering Medicare Advantage plans too often delay and deny care inappropriately. If you happen to live in a low-income community, you are more likely to be forced to join a Medicare Advantage plan that does not cover the care to which you are entitled under Medicare, according to a new analysis by Avni Gupta et al. published in JAMA. This analysis adds to the mountains of evidence that insurers are fostering health inequities among Black, Hispanic and other vulnerable Americans in Medicare Advantage.

    To be clear, you should not assume that if you are a middle-class white American in a Medicare Advantage plan that you will get the care you need. Even Medicare Advantage plans with five-star ratings delay and deny care inappropriately. And, there is no way for you to know which ones do.

    You are better off in traditional Medicare if you get sick and need costly and complex care. You can choose your physicians and you will get the care you need in a timely manner without bureaucratic hassle. But, you will need Medicare supplemental insurance or Medigap, to protect you from financial risk. With Medigap you will have few out-of-pocket costs, but it will cost you around $2,500 a year. While Medicare Advantage plans have an out-of-pocket cap, your out-of-pocket costs for in-network care alone can be as high as $8,850 this year, depending upon the Medicare Advantage plan you join. If you go out-of-network, your costs will be even higher.

    But, if you live in a low-income community, you are more likely to have fewer choices of Medicare Advantage plans with five-star ratings. And, it is fair to assume that plans with one, two, three and four-star ratings should be avoided. If a plan is not able to earn a five-star rating, there’s likely something wrong with its performance.

    Put differently, it is harder to enroll in a Medicare Advantage plan with a five-star rating if you live in a community with greater poverty and unemployment. As a result, you are likely to experience worse health outcomes. Specifically, you are more likely to receive poorer chronic care management and less likely to receive screenings and vaccinations. Customer service is more likely not to be good. And, if your Medicare Advantage plan inappropriately denies the care you need, it could be harder to challenge that denial.

    Here’s more from Just Care:

  • What we don’t know about Medicare Advantage

    What we don’t know about Medicare Advantage

    [Editor’s note: The following is the response to a request for information about Medicare Advantage data gaps by the Centers for Medicare and Medicare Services, from a coalescence of grassroots organizations and others.]

    May 29, 2024

    The Honorable Chiquita Brooks-LaSure Administrator
    Centers for Medicare and Medicaid Services
    U.S. Department of Health and Human Services
    200 Independence Avenue, SW Washington, DC 20201
    The Honorable Xavier Becerra, Secretary
    U.S. Department of Health and Human Services
    200 Independence Avenue, SW Washington, DC 20201

    Re: CMS-4207-NC–Medicare Program; Request for Information on Medicare Advantage Data Submitted electronically via https://www.regulations.gov

    Dear Administrator Brooks-LaSure and Secretary Becerra,

    Thank you for providing us with the opportunity to share our views on Medicare Advantage (MA) data gaps and needs in order to make critical improvements to MA. Like you, our goal is to promote health equity, protect enrollees, and ensure the fiscal integrity of the Medicare program. Right now, with limited, untimely and incomplete MA data, these goals are a pipe dream.

    This response to the MA Data request for information is submitted on behalf of the below signed organizations and individuals representing a wide and diverse swath of stakeholders. We believe that critical data gaps today undermine MA accountability and allow bad actors to gouge taxpayers, erode the Medicare Trust Fund, endanger the lives and well-being of older adults, and discriminate against Black, Hispanic, Pacific Islander, low-income and critically ill older adults and people with disabilities.

    We salute CMS for trying to enhance enrollee protections in MA but, without better data, there is no way to protect people from plans that do not honor their obligations to cover Medicare benefits and other contractual obligations. CMS cannot cancel their contracts or penalize them appropriately. CMS cannot warn people about MA plans with unconscionably high denial rates, inadequate networks, or high mortality rates. Unfortunately, the available data suggests there are far too many of them.

    We agree with you that we should “have, and make publicly available, MA data commensurate with data available for Traditional Medicare to advance transparency across the Medicare program, and to allow for analysis in the context of other health programs.” Not only is that not the case today, but we know from MedPAC that insurers have never met their obligation to release complete and accurate encounter data. That failure alone indicates either an inability of insurers to effectively manage care, or a blatant disregard for the value of this data for effective oversight, or perhaps a desire to hide the data to avoid appropriate accountability for their bad acts. Whatever the reasons, it is essential that any and all data requirements from insurers be fashioned in ways that ensure their complete, accurate and timely collection and impose appropriate non-discretionary penalties for insurers’ failure to provide the data.

    Without complete, accurate and timely plan-level data, adequate resources for oversight and meaningful penalties for noncompliance, the MA program has become an ATM for the health insurers offering MA plans. This makes the MA program a dangerous choice for older adults and people with disabilities who too often wrongly assume what they are told — that they will get the Medicare benefits to which they are entitled. Further, it makes the MA program an administrative nightmare and a financial risk for providers. If Congress and the administration do not have the tools to identify and punish insurers who withhold Medicare-covered services from MA enrollees or otherwise discriminate against them, they should acknowledge the MA program’s vulnerability to corporate crime and serious or deadly enrollee harm — and overhaul or end the program.

    Recently CMS chose not to call for more detailed data reporting from MA insurers. Rather, it said that “reporting at the specialty level and service level could be overwhelming because of the volume of information presented.” If CMS cannot manage the collection and analysis of granular data to police the insurers offering MA plans effectively, CMS should publicly disclose those constraints and their dangerous consequences, call upon Congress for the needed resources, and warn enrollees upfront and clearly of its inability to protect them from bad actor insurers who have the ability and the financial incentive to deny them needed care.

    We detail below some of the most critical data gaps and needs to prevent the MA program from offering choices to older adults and people with disabilities that no one should have to make, gouging taxpayers and the Medicare Trust Fund, and disrespecting the financial and administrative needs of providers. Before we do, we want to underscore our shared goal with the administration of promoting health equity and the need for a lot more MA data to accomplish this goal.

    That said, if the government simply requires more MA data without robust oversight and non-discretionary penalties on insurers for non-compliance, the requirements would be of little value. The government must use the data to oversee the MA insurers and hold the bad actors accountable for their bad acts in meaningful ways.

    Moreover, if the government simply expects beneficiaries to make sense of volumes of Medicare data to protect themselves against bad actor MA plans or to appeal systemic inappropriate denials of care in order to get the Medicare benefits to which they are entitled, it is promoting health inequities. If the government allows MA plans to hide the data revealing that lower-income enrollees and communities of color are going without needed care because of administrative and financial burdens and inappropriate denials, it is promoting health inequities. CMS must keep bad actor MA plans out of the program and reform the MA program to minimize harm to enrollees.

    In a sadly apt comparison, the Boeing aerospace corporation was allowed to continue its money-saving profit-centric business model that led to the needless deaths of many people before Boeing was forced to suffer material consequences. We have mounting evidence that the worst performing MA plans are behaving similarly, with arguably far more horrific consequences both for their tens of thousands of enrollees and for the Medicare program writ large. And no one is yet identifying these bad actors, let alone stopping them.

    Inadequate provider networks and misleading directories cause harm

    The government cannot protect people enrolled in MA if it cannot block MA plans with inadequate networks or prevent sales agents from misleading people about networks. Today, it cannot do either, even though CMS “requires” insurers to offer adequate networks and restricts the activities of MA sales agents. Consequently, people sign up for MA plans thinking they will get the care they need from the physicians and hospitals they want or need to use and too often find they are not covered for their care from those providers. The network provider directories are inaccurate. They often can’t use a cancer center of excellence. Or, they can’t see a physician at a convenient location. Or, all of the nursing homes in their network are of poor quality. As you know, the plight of enrollees who need costly care is all the worse for Black and Hispanic people, low-income people and people in rural communities—promoting grave and unconscionable health inequities.

    CMS allows insurers to offer MA plans with different networks in a contract and only collects network information at the contract level, preventing it from ensuring network adequacy. CMS likely lacks the resources to oversee more than 4,000 MA plans effectively. To protect enrollees, this cannot continue.

    CMS could require insurers to offer the same provider network to all MA plans in a contract. That requirement would simplify oversight of network adequacy and provider directories. It also would help promote health equity, prevent provider network discrimination, and allow for more meaningful plan choice.

    The simplest way for CMS to collect accurate provider network data would be to create a central web portal on which all providers are required to list their MA plan affiliations. Insurers would then be responsible for ensuring accuracy and could penalize network providers who were not listed. People could far more easily compare MA plan networks.

    The best solution would be for CMS to require all MA plans to eliminate their networks and cover all willing Medicare providers at the Medicare rate.

    Again, whatever CMS chooses to do, it is of no use if the insurers do not have adequate networks. It is of no use if the insurers are not accountable for failing to provide accurate provider information less than 95 percent of the time or failing to have adequate networks. CMS should impose a non-discretionary meaningful penalty on these insurers in the form of a lower star rating, an X or other warning about the plan on its web site or a requirement to stop all marketing. Insurers should be held strictly liable for their errors. Enrollees should not be their victims.

    Additionally, as the Center for American Progress recommends, “CMS should ensure there are explicit protections that would allow for an enrollee to change MA plans or return to TM without being subject to medical underwriting for supplemental Medigap policies if their MA plan directory was inaccurate at their time of enrollment. For example, CMS can clarify that if an enrollee makes such a discovery, it should be considered a misleading MA practice and accordingly trigger a Special Enrollment Period (SEP) for supplemental benefits.”

    Proprietary and non-evidence-based prior authorization rules cause harm

    If MA prior authorization rules have health benefits, insurers should share them openly and freely use them. If not, insurers should be penalized heavily for using them, especially in cases where people’s lives and health are at serious risk, such as for cancer patients. Otherwise, Congress and the administration cannot protect Medicare Advantage enrollees from grave harm.

    For this reason, CMS must require insurers to disclose all prior authorization requirements they intend to use, and CMS must pre-approve them based on evidence. Penalties for non-compliance should be severe and non-discretionary. Insurers should be stopped from making people with Medicare their victims.

    To truly protect people, CMS should dictate the prior authorization rules that MA plans are permitted to use. Specifically, CMS should create a standardized prior authorization system that applies to all MA plans. Only a standardized system will promote health equity and allow people to make an informed MA choice.

    For now, in its insurer contracts, CMS should prohibit insurers from using different prior authorization rules for enrollees depending upon the MA plan they are enrolled in. There is no good rationale for allowing an insurer to discriminate against people in some MA plans through use of more prior authorization rules than other MA plans. Either prior authorization is beneficial and clinically sound or it is not.

    Recent CMS prior authorization rules are a good first step. But, without more details and non-discretionary penalties for plans that apply PA inappropriately, history and experience suggest that insurers will ignore such rules. To repeat, the only way for CMS to ensure MA enrollees get the same Medicare benefits as people in TM — and protect MA enrollees from deadly delays and denials of care as a result of PA — is for CMS to set standardized PA rules. To ensure and promote health equity, CMS should require insurers report PA denial and delay data by type of service and enrollee characteristic at the plan level.

    Insurers should also report MA plan level denials both pre and post treatment and in and out of network. CMS needs the information to ensure insurer compliance with Medicare coverage rules. Individuals need this information to avoid plans with high denial rates. Providers need this information to make informed choices about which networks to be a part of.

    Supplemental benefits are a gift to insurers who wrongly and excessively deny care

    Based on the existing evidence, it is all but certain that insurers are able to offer extra benefits and still profit handsomely because of the money they save from denying care inappropriately, keeping enrollees from seeing high quality providers, attracting a disproportionate share of healthy enrollees and creating incentives for enrollees with costly conditions to disenroll.

    CMS should automatically forbid plans with denial rates above 10 percent in the prior year from offering supplemental benefits. While this would likely mean fewer supplemental benefit offerings, as the Center for American Progress says, “The little research that is available suggests that MA plan coverage for dental, vision, and hearing services has not resulted in improved access for beneficiaries.”

    Immediately, along with the Center for American Progress, “We recommend that CMS collect and publish utilization and OOP spending data for all supplemental benefits, disaggregated by enrollee race, ethnicity, gender, income level, and other important demographic characteristics, at both the plan and beneficiary level. This information should be stratifiable by benefit transaction/service type. We also recommend that complete data on the use of prior authorization for supplemental benefits, including rates of denials on PA requests, be reported to CMS and made publicly available.”

    High disenrollment or mortality rates should disqualify an insurer from offering an MA plan

    CMS should require insurers to report MA plan-level disenrollment and mortality rates. The data should be broken down across demographic and health characteristics of the people who disenroll or die and should be publicly reported. Disproportionately high rates automatically should trigger cancellation of MA contracts. High rates should also trigger lower MA star ratings. Given that some plans have excessively high denial and mortality rates, people choosing an MA plan can only make a meaningful choice with this information. Star ratings that do not meaningfully reflect excessive mortality rates are a cynical perversion of quality methodologies.

    Out-of-pocket costs force people into debt and to forgo care

    CMS should collect and report plan level data on the number of people forgoing critical care based on cost or care denials. How many people in MA are forgoing critical care as a result of high out-of-pocket costs that their MA plan imposes? How many of them are low income, in poor health or are Black or Hispanic? How can CMS promote health equity without this information?

    CMS should collect and report plan level out-of-pocket costs by health condition. What are people’s out-of-pocket costs if they have cancer, suffer a stroke, or need rehab? How can people make an informed choice of an MA plan without this information?

    CMS should collect MA plan-level data to promote health equity

    CMS needs MA plan-level data to promote health equity or it needs to forbid insurers from offering more than one MA plan in a contract area.

    To echo the Center for American Progress, “CMS should consider including some dimension of equity as part of the MA star ratings program, which at the very least could be a reflection of whether MA plans are collecting adequate and stratifiable data.” And, “CMS should prioritize making any necessary adjustments to its race and ethnicity data collection processes given how central accurate underlying data is to the validity of monitoring for inequities.”

    Without oversight and enforcement, data requirements are virtually useless

    We know that tens of thousands of people each year in MA, if not hundreds of thousands, are dying needlessly or suffering greatly because Congress created a program that is impossible to oversee and the insurers have become so big and powerful, both legally and politically, that they can design their MA plans to maximize profits and violate contracts with near impunity.

    The data on health insurance violations reported on violationtracker.org speaks volumes.

    No other wealthy nation allows health insurers to behave as they will to deny and delay care or otherwise restrict care access as MA insurers are able to do. No other wealthy nation provides insurers with an incentive to maximize profits on the backs of their enrollees. Rather, they dictate when, how and where care is covered—and the price. That’s the way to ensure insurers do their job appropriately and protect people.

    A lot more data is urgently needed for adequate oversight. But, without tens of billions of dollars more, CMS will not be able to conduct effective oversight and enforcement. Insurer abuses will persist and vulnerable older adults and people with disabilities will suffer. Only much tighter regulation and non-discretionary automatic penalties for non-compliance will promote health equity and ensure MA enrollees get the care to which they are entitled.

    Conclusion

    This year alone, the government is projected to overpay insurers offering Medicare Advantage plans between $83 and $127 billion, wasting taxpayer dollars and driving up Medicare premiums, indicating serious design defects in the government’s capitated payment structure. Moreover, notwithstanding critical missing data, mounting evidence reveals serious deficiencies in MA’s coverage design, resulting in untold harm to a significant number of enrollees who need critical care.

    Rules and regulations, limited resources, and corporate health insurer power have kept CMS from collecting critical data, auditing plans adequately, and enforcing penalties. Rather, MA is growing quickly, and few people enrolled appreciate that they are taking a big gamble with their health. Medicare Advantage saves money for healthy people, but comes with serious costs and major limitations for the most vulnerable. Instead of pooling and spreading risk, the MA model allows insurers to fragment risk, burdening the sickest; the opposite of a proper insurance design.

    Traditional Medicare is far from perfect and needs improvements, including an out-of-pocket cap. But, it is far more cost-effective than MA. In sharp contrast to MA, Traditional Medicare pools and spreads risk. It is designed to ensure that the 10 percent of enrollees responsible for 70 percent of Medicare spending have quick and easy access to needed care. Traditional Medicare does not create obstacles to care, or second-guess enrollees’ treating physicians in order to maximize profits, much less withhold data in order to prevent appropriate oversight.

    We know that political pressures can prevent dramatic action, often when it is most necessary. We hold Congress largely responsible for refusing to act in meaningful ways to reform MA. And, we thank CMS for calling on the public to bring attention to MA’s limitations, as well as for improving MA as best it can, given so many constraints.

    We hear the nightmare Medicare “Disadvantage” and “Take Advantage” stories on the ground and struggle to sleep at night, concerned for the millions of vulnerable Americans who can’t afford supplemental insurance in TM and have no clue of the challenges they are likely to face in MA when they most need care. We will continue to highlight MA’s inequities and defects and advocate for major reforms to the program, alongside the Office of the Inspector General, the Government Accountability Office, the MedPAC, the Committee for a Responsible Federal Budget, the American Hospital Association, a growing number of Congresspeople and myriad others. We promise that we will not stop speaking out until the day our representatives in Congress unite to pass legislation that will protect MA enrollees and the fiscal integrity of the Medicare program.

    In the meantime, we appreciate your consideration of our comments. For any questions regarding this comment letter, please contact Diane Archer at [email protected].

    American Economic Liberties Project
    Be A Hero
    Center for Economic and Policy Research Center for Health and Democracy
    Center for Medicare Advocacy
    Just Care USA
    People’s Action
    Physicians for a National Health Program
    Public Citizen
    Puget Sound Advocates for Retirement Action
    Social Security Works
    Dr. Don Berwick, Former Administrator of the Centers for Medicare and Medicaid Services (CMS)

  • UnitedHealth claims enrollees cannot challenge inappropriate care denials in court

    UnitedHealth claims enrollees cannot challenge inappropriate care denials in court

    Several months ago, Stat News exposed a common practice at UnitedHealth care and other big insurers: Large numbers of Medicare coverage denials through the use of AI. Bob Herman now reports for StatNews that UnitedHealth care claims a judge should dismiss a class action lawsuit against it because enrollees did not exhaust administrative remedies for appealing denials.

    UnitedHealth is able to deny people coverage in Medicare Advantage with impunity and profit from its failure to comply with Medicare coverage rules. It knows that only a small fraction of people will appeal denials, so it can save money by not paying for care. It also knows that the Centers for Medicare and Medicaid Services, which oversees Medicare, does not have the resources to adequately oversee MA plans or the power to impose meaningful penalties on insurers when they violate their contracts and deny care inappropriately.

    So UnitedHealth allegedly denied thousands of Medicare Advantage enrollees’ rehab therapy using an algorithm, without regard to the individual needs of its enrollees. And, now it’s claiming that their class action lawsuit against UnitedHealth for these denials should be dismissed because the vast majority did not exhaust their full appeal rights. (In addition, UnitedHealth claims that federal law protects insurers from these lawsuits; it argues that enrollees must sue the Department of Health and Human Services.)

    UnitedHealth blames the federal government for their enrollees’ plight, a novel. If the appeals process were swifter, UnitedHealth claims, plaintiffs would not be suing.

    The reality, of course, is that older vulnerable patients should not have to appeal inappropriate denials of necessary care; they should not face these denials. They wouldn’t have to if United considered their individual needs in making coverage determinations and put those above their shareholders’ needs. But, UnitedHealth’s shareholders’ needs appear to come first and that means Medicare Advantage enrollees might not get the Medicare benefits to which they are entitled.

    We will know soon whether the judge in the lawsuit agrees with UnitedHealth that plaintiffs claims should be dismissed because they did not exhaust their administrative remedies. Plaintiffs say that had they done so, they would have suffered irreparable harm. They needed care quickly and couldn’t afford to pay for it out of pocket.

    The government designed the Medicare Advantage program with a major payment system defect. It pays the insurers upfront to deliver Medicare benefits, and what the insurers don’t spend on care they largely get to keep. So, they have a powerful incentive to deny care inappropriately.

    Here’s more from Just Care:

  • Cigna medical directors given little incentive to review prior authorization denials thoroughly

    Cigna medical directors given little incentive to review prior authorization denials thoroughly

    A new Pro Publica report exposes how Cigna requires its medical directors to review prior authorization denials at breakneck speed, preventing patients from getting critical care. One medical director at Cigna revealed that, as of about five years ago, she was required to review so many coverage denials in a day as to keep her from ensuring patients received appropriate coverage for their care. This is yet another reason why enrolling in a Medicare Advantage plan entails significant risk if you develop a costly condition.

    Some states allow health insurance company nurses to decide whether someone in the US should get treatment without oversight by a physician. But, some states do not allow insurers to deny claims without a doctor reviewing them. In those states, a medical director must review the nurses’ decisions; but, health insurers can determine how long their medical directors spend on these reviews.

    A few years ago, Cigna began hiring nurses in the Philippines to make coverage determinations. Cigna’s medical directors in the US reviewed their denials. Dr. Debby Day, a Cigna medical director, explains that Cigna was not giving her the requisite time to do so.

    According to Dr. Day, the nurses in the Philippines have increasingly been inappropriately denying Cigna enrollees coverage. She refused to rubber stamp the nurses’ denials or “click and close” them as many of her fellow medical directors did.

    “Deny, deny, deny. That’s how you hit your numbers,” said Dr. Day, who worked for Cigna until the late spring of 2022. “If you take a breath or think about any of these cases, you’re going to fall behind.”

    In response to a Pro Publica query, Cigna claimed that its medical directors were not permitted to click and close nurses’ care denials. But, Cigna shared information about the number of case reviews each medical director was performing—“the productivity dashboard”– with all of them as a way to boost their productivity. The medical directors who performed fewer reviews were considered less productive.

    Companies in many industries typically study the efficiency of their workers. But, in health care, speedy reviews can lead to inappropriate denials of critical care or coverage for services.

    In January and February 2022, Cigna gave medical directors four minutes to review a prior authorization decision for an expensive treatment. Cigna gave them as little as two minutes to review a request for drug coverage. And, it gave medical directors just four and a half minutes to determine whether a patient should be discharged from hospital.

    As has been previously reported, Cigna and other insurers often use an algorithm to reject certain claims collectively.  On average, medical directors spend 1.2 seconds on those claims.

    Dr. Day spent more time reviewing coverage determinations than most of her peers. She felt that Cigna rewarded those who spent less time reviewing these determinations, without considering the quality of their work.

    In response to a question from Pro Publica about incentives to deny claims, Cigna argued that it took less time to approve them, failing to acknowledge that their nurses did the time-consuming work to “justify” denials and that clinicians simply had to click and close.

    Dr. Day explained that during the first several years she worked at Cigna, she was able to take the time she needed to review cases appropriately, but that all changed a few years ago. Once Cigna hired nurses in the Philippines to conduct the initial case review, Dr. Day found  a lot of mistakes in their case reviews that could lead to inappropriate denials. For example, nurses mistook a patient’s parent for the patient, a patient’s hip for her neck, and a patient’s STD for toenail fungus.

    Dr. Day said that Cigna was not focused on her correcting its nurses’ erroneous denials; rather, it was focused on her need to be more efficient. Cigna told her that if she did not review more cases and boost her productivity score, she could be fired. It’s no surprise she left the company.

    Here’s more from Just Care:

  • UnitedHealth care delays, denies and grows ever bigger

    UnitedHealth care delays, denies and grows ever bigger

    At the same time that UnitedHealth is growing its Medicare Advantage business, it is growing many of its other businesses and controlling a sizeable portion of the health care sector, often to the detriment of patients and providers. Dan Diamond, Christopher Rowland and Daniel Gilbert report for the Washington Post on the attention Congress is now giving to UnitedHealth. Will Congress rein in UnitedHealth and hold it accountable for its bad acts. Can the federal government break up UnitedHealth at this point, or is it too big to fail?

    Chairman Ron Wyden, who heads the Senate Finance Committee, is holding a hearing with Sir Andrew Witty, UnitedHealth’s CEO. United is now a $400 billion company, with $22 billion in profits in 2023, and the biggest health insurer, as well as the biggest employer of physicians in the US; it employs about 10 percent of providers. It also processes about a third of provider claims for reimbursement through its Change Healthcare subsidiary. Recently, its cybersecurity system was hacked, and UnitedHealth forced tens of thousands of physicians and hospitals to go without pay; some providers were forced to take out loans and some patients had to pay out of pocket for care.

    It is not at all clear why UnitedHealth did not address grave gaps in Change Healthcare’s security when it acquired the company a few years ago. Nor is it clear that UnitedHealth is holding anyone at the corporation accountable for this failure.

    How can Congress help ensure UnitedHealth appropriately covers care and coverage and hold the corporation account when it fails to do so? In the words of Don Berwick, former head of the Centers for Medicare and Medicaid Services, “They’ve grown too big for this country’s good, and for their own good.” “They became the best at playing the game of charging the federal government more and using that wealth to gain political power, advertising power, some changes in benefits.” Some say UnitedHealth presents an economic and national security risk.

    Republicans and Democrats agree that the size and power of UnitedHealth raises serious concerns. Senator Wyden, a Democrat, wants Witty to explain his company’s use of prior authorization, which too often keeps people from getting needed care. He is concerned with the ways UnitedHealth increases health care costs. Congressman Buddy Carter, a Republican, says “It needs to be busted up.” Here, here!

    The Justice Department has tried to prevent some of UnitedHealth’s mergers and acquisitions, but UnitedHealth has put up legal challenges and tends to prevail. Hayden Rooke-Ley, a senior fellow at the American Economic Liberties Project, an antitrust-focused nonprofit, explains the consequences: “What we are seeing now is there are really significant risks of letting a company like United own a physician group, ambulatory surgical centers, a mail order pharmacy, home health providers … and claims processing and revenue cycle management.”

    The fact remains that a number of Democrats and Republicans receive significant campaign contributions from UnitedHealth, which they depend upon. Moreover, many policymakers receive veiled threats from UnitedHealth if they don’t support the corporation. For now, you can expect UnitedHealth to grow and our healthcare system to remain at serious risk of higher costs and inappropriate denials of care as a result.

    Here’s more from Just Care:

  • States address prior authorization denials, while Congress fears to tread

    States address prior authorization denials, while Congress fears to tread

    People across the country are facing increasing numbers of treatment denials from insurers, even after their insurers have approved these treatments for extended periods. Shalina Chatlani reports for Medical Express on how some states are addressing these prior authorization denials that are undermining patients’ continuity of care and causing them serious hardship. Meanwhile, Congress has been unwilling to act in meaningful ways.

    One patient suffering from chronic pain had been getting monthly infusions for pain relief. Then, Medicaid refused to cover these infusions. After many months, the corporate insurer administering Medicaid benefits decided to overrule the patient’s treating physician and deem the treatment medically unnecessary.

    Prior authorization denials keep health care spending down. They also enrich the insurers that contract to deliver Medicare and Medicaid services as well as coverage for working people. They are generally paid a fix rate upfront. What they don’t spend, they are largely able to keep for themselves, so they have an incentive to deny care or delay care. It helps to maximize their profits.

    Insurers leave patients without needed treatments, often to the detriment of their health and sometimes their lives. States have been stepping in to reduce the number of prior authorization delays and denials. Nine states have laws in place now to protect patients.

    New Jersey addresses insurer delays of care by requiring insurers to make determinations as to whether care is covered within 72 hours of a request. In Texas, doctors whose requests to provide care are approved 90 percent of the time receive a “gold card” that eliminates their need to seek prior authorization. But, to date, only three percent of doctors in Texas have gold cards.

    Washington has a law that ensures insurers make swift prior authorization determinations. Michigan ensures that insurers use only prior authorization processes that are peer-reviewed and approved. Arizona is considering a law that would require insurers to honor their own, or another insurer’s prior authorization determination if someone switched insurers, within 90 days of the determination. But, it would not apply to Medicaid patients.

    What’s insane is that our federal government effectively trusts insurers to implement prior authorization rules that are evidence-based and appropriate, with little oversight to ensure that is the case, even though mountains of evidence indicate that it is not. Moreover, the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare and Medicaid, has little ability to hold insurers accountable when they violate prior authorization regulations.

    A new CMS rule is intended to speed up insurer prior authorization decisions for medical services. It goes into effect in 2026. But, it has no meaningful enforcement mechanism. As well, inexplicably, it does not apply to insurer determinations as to whether a drug is covered.

    State laws, for the most part, only apply to private health insurance that is state-regulated. Consequently, people in ERISA plans, who work for companies that self-fund their health insurance, are not protected by state laws. These laws also generally do not protect people with Medicaid.

    One recent study found that one in five people with cancer are denied care their treating physicians recommend. The American Medical Association found that patients often experience “serious adverse event(s)” as a result of prior authorization processes.

    Even when states are able to detect violations by insurers and hold them accountable, the penalties generally are so small as not to be a deterrent for the large insurers. One expert suggested holding insurance company medical directors accountable for wrongful prior authorization determinations; medical directors could be sued for malpractice. Oklahoma is considering a law that would do that.

    Here’s more from Just Care:

  • Medicare Advantage: Expect lots of care denials

    Medicare Advantage: Expect lots of care denials

    If you’re in a Medicare Advantage plan or any other corporate health insurance plan and need costly care, you can expect a denial from your insurer about once every seven times you seek treatment, reports Jeff Lagasse for HealthcareFinanceNews. A new national survey by Premier found that insurers deny almost 15 percent of claims for reimbursement, including claims for care that the insurers had authorized. And, insurers offering Medicare Advantage plans require prior authorization about 25 percent of the time.

    Insurers sometimes do not pay hospitals, health systems and nursing homes, even after they have okayed delivery of care. To be clear, insurers can deny payment with impunity, allowing them to hold onto assets. They challenge providers to appeal their decisions, a tactic that serves insurers’ bottom lines well.

    Insurers end up paying more than half of the claims that they deny initially. However, they only do so if providers are willing and able to go through a time-consuming and costly appeal process. For the providers, it is usually worth appealing since insurer denials are generally for costly charges.

    Health care providers spend nearly $20 billion each year appealing insurance corporation denials. That breaks down to $43.84 per claim on about three billion claims. Providers incur additional costs from the need for more clinical work–$13.29 for an inpatient stay and $51.20 for inpatient surgery, according to  American Medical Association estimates.

    Even when providers prevail on appeal, they generally can wait as long as six months after treating patients to get paid. Not surprisingly, many hospitals are hurting. In stark contrast, UnitedHealth and Cigna have around 25 percent more cash on hand today than they did five years ago.

    People with corporate health insurance not yet eligible for Medicare might not get the care they need for fear of having to pay out of pocket for it. About half say that they couldn’t pay a $1,000 hospital bill in 30 days time, according to a Commonwealth Fund report. Forty-six percent say they skip or delay needed care because they can’t afford to pay for it.

    People with Medicare should never be responsible for bills Medicare or their Medicare Advantage plans don’t pay. But, their doctors and hospitals might not provide them needed care, concerned that they won’t be paid for it.

    Premier’s survey found that people in Medicare Advantage plans needing skilled nursing facility care are especially likely to face denials. Insurers deny about one in five provider requests for discharge from a hospital to a skilled nursing facility.

    CMS needs to collect data on MA insurer payment delays and denials. Inappropriate delays and denials violate insurers’ contractual obligations.

    Here’s more from Just Care:

  • Ady Barkan’s Legacy: Reclaiming Medicare from insurance corporations

    Ady Barkan’s Legacy: Reclaiming Medicare from insurance corporations

    Ady Barkan, my dear friend and former colleague, spent the last years of his life fighting to give everyone in America the right to high-quality healthcare. He knew that he was dying, and used his own story to shine a light on why “the richest country in the history of the world” could figure out how to provide it. He evangelized the virtues of Medicare For All, yet came to understand that a powerful force stood in the way: So-called “Medicare Advantage” (MA) plans. These plans are not Medicare. They are privatized alternatives run by for-profit insurance corporations.

    As Ady wrote a little over a year ago, these privatized plans threaten our cherished public benefit of Medicare. They siphon up our public dollars, overcharging the government to the tune of billions a year. Then, they delay and deny the care the patients need. Their goal is to generate profit by charging as much as possible to provide as little healthcare as possible.

    The government allows privatized plans to offer benefits Traditional Medicare is barred from covering, including dental, vision, hearing, and an out-of-pocket cap. This makes them an attractive option, particularly to younger and healthier patients. It is only once people get sick, and need to use their coverage, they realize these plans are a scam.

    The government needs to hold these plans accountable for their greed, not give them a raise.

    With Traditional Medicare, you can use the doctor and hospital of your choice, and they provide the care that you need. Medicare Advantage restricts your choice of doctors and hospitals, as well as what type of care they can provide. These might seem like minor nuisances when you’re relatively healthy, but can mean the difference between life and death when you’re sick.

    That’s not an exaggeration. A recent study found that Medicare Advantage patients are 1.5 times more likely to die in the month after complex cancer surgery than Traditional Medicare patients. Another study found that if the government canceled contracts with the worst performing 5% of MA plans, it would save 10,000 lives a year.

    Yet despite Medicare Advantage plans providing worse care than Traditional Medicare, they cost the government more money—an average of 6% per patient—despite the fact that Medicare Advantage patients are generally younger and healthier than those with Traditional Medicare. They are overcharging the government by up to $140 billion a year. This is money that comes out of the Medicare trust fund, endangering the future of the entire program. Yet it still isn’t enough for health insurance corporations offering these plans.

    The government is proposing a 3.7% increase in payments to Medicare Advantage plans for next year. They plan to finalize that amount at the beginning of April. The health insurance corporations and their lobbyists are pressuring the government to increase that amount. They are even insisting that a 3.7% increase is a cut, just because it’s not as much as they want!

    This is outrageous. The government needs to hold these plans accountable for their greed, not give them a raise. Over 25,000 Americans are calling on President Joe Biden to do just that. As their petition says, these plans should be paying us back, not the other way around.

    Be A Hero, the organization Ady founded, is one of the organizations at the forefront of this fight. Hundreds of our grassroots supporters have shared their painful stories of being delayed or denied care by faceless, cruel insurance companies. Others reveal feeling tricked or even forced onto a Medicare Advantage plan and then being stuck in the “Hotel California.” Their heartbreaking stories called Ady and now call all of us to take action.

    We are joined by doctors, patients and experts from across the country who see the existential threat posed to Medicare by insurance corporations. Reclaiming Medicare from corporate greed is an essential part of Ady’s legacy. It is the only way we can move towards Ady’s vision of Medicare for All—guaranteed high-quality healthcare for everyone.

    [Editor’s note: This post originally appeared in Common Dreams on March 28, 2024.]

    Here’s more from Just Care:

  • Three big Medicare access to care issues put vulnerable people at serious risk

    Three big Medicare access to care issues put vulnerable people at serious risk

    The Centers for Medicare and Medicaid Services has issued its annual Medicare Advantage (MA) proposed rate notice for 2025 and is seeking comments before it finalizes the rate. It is trying to combat tens of billions of dollars in annual overpayments to Medicare Advantage plans. Right now, they result in about $25 billion a year in higher premiums for Medicare enrollees. If not terminated, these overpayments will, over time, destroy Medicare, making it unaffordable for the older adults and people with disabilities who rely on it for their medical care.

    What are the big issues with Medicare today?

    Traditional Medicare, which gives people easy access to care from physicians and hospitals across the US, is not an option for people with low incomes because it lacks an out-of-pocket cap, and Medigap is unaffordable or unavailable to them. MA plans are good while you’re healthy, but that’s not why we have health insurance. When you develop cancer and other costly conditions, MA plans have a powerful financial incentive to stint on care and few constraints since they face little accountability for their bad acts. Non-standardized administrative processes, including claims processing and prior authorization protocols, mean inappropriate delays and denials, ineffective CMS oversight and no way to protect people, particularly people with costly conditions, from bad actor plans.

    People cannot make meaningful Medicare choices. Information is misleading and inadequate to keep people from joining MA plans that impose inappropriate barriers to care and endanger their health when they get sick. CMS tells them they’ll get the same benefits in Medicare Advantage as Traditional Medicare. But, it’s not true. Some plans have high denial rates, ghost networks, inappropriate prior authorization obstacles, high mortality rates. People can’t avoid them. MA plans compete to maximize profits not to promote high value care for those who most need it. CMS can only protect them if there is significantly more MA standardization. Greater standardization of out-of-pocket costs and claims processing would help promote meaningful choice and appropriate coverage. CMS also needs resources to enable appropriate oversight and enforcement.

    Non-standardized Medicare Advantage administrative processes enable inappropriate care denials: So long as CMS cannot protect vulnerable individuals from MA plans that impose harmful barriers to care, TM needs to be a meaningful choice. Until Congress acts, CMS should use CMMI, its innovation center, to test a Traditional Medicare model with low out-of-pocket costs and an out-of-pocket limit that is on a more level playing field with Medicare Advantage. If TM is not on a level playing field with Medicare Advantage, Traditional Medicare will disappear, there will be less choice and higher costs for Medicare Advantage enrollees, the vulnerable will be most at risk. To help protect vulnerable MA enrollees, CMS should require MA plans to use a centralized independent agency to do claims processing and prior authorization so that plans compete to deliver better managed and coordinated care, not to avoid covering care for people with complex conditions.

    Notwithstanding CMS’ efforts to address some of the problems with prior authorization and inappropriate delays and denials of care, proprietary and non-standardized claims processing and prior authorization rules mean inappropriate delays and denials, ineffective CMS oversight and no way to protect people, particularly people with costly conditions, from bad actor plans. Without an independent intermediary to process claims in a timely and standardized manner, vulnerable enrollees have a good chance of not getting the medically necessary care to which they are entitled; and, the bad actor MA plans will go undetected, to the detriment of their most vulnerable enrollees.

    Here’s more from Just Care:

  • Medicare Advantage cannot rely exclusively on AI to deny coverage

    Medicare Advantage cannot rely exclusively on AI to deny coverage

    For some time now, UnitedHealth and other health insurance companies are reported to have been using artificial intelligence tools to broadly deny coverage in certain instances for people enrolled in Medicare Advantage plans. Insurers claim that the tools simply help them determine whether to deny a service. Use of these tools appears to have led to large numbers of inappropriate denials of care for Medicare Advantage enrollees, and the Biden administration is now stepping in reports SkilledNursingNews.

    The Centers for Medicare & Medicaid Services (CMS), which oversees Medicare, is restricting insurers’ ability to use AI tools to deny claims for Medicare Advantage enrollees. It issued an FAQ to insurers offering Medicare Advantage plans to ensure insurers understand that Medicare Advantage plans cannot deny care without considering individual patient’s needs.

    The FAQ explains how insurers can use algorithms and AI in Medicare Advantage. And, it clarifies coverage requirements for post-acute care to help ensure patients aren’t wrongly denied critical care. Insurers can use prior authorization, but not in an emergency or urgently needed care situations or for out-of-network services they cover.

    While insurers can use AI in determining whether to cover a service, they are responsible for making sure that the AI complies with the Medicare coverage rules. And, they can’t rely exclusively on AI. Insurers offering MA must consider each individual enrollee’s situation, including the enrollee’s medical history and treating physician’s recommendation, in deciding whether care is medically necessary. And, before an insurer ends services for MA enrollees, their individual conditions must be reevaluated.

    Furthermore, insurers must publicly release their coverage criteria on a website and cannot change it as they please, according to CMS. And, if your doctor says you need post-acute care in a rehab facility, your health insurer cannot second-guess that decision so long as you meet Medicare coverage criteria for such care.

    If an insurer still denies coverage, it bears the burden of proof on appeal that care is not medically necessary through a detailed explanation. And, a provider with expertise in that care must issue the denial.

    Here’s more from Just Care: