JustCare

Tag: Denial

  • AHA underscores dangers of Medicare Advantage, need for greater accountability

    AHA underscores dangers of Medicare Advantage, need for greater accountability

    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:

     

  • OIG finds widespread inappropriate care denials in Medicare Advantage

    OIG finds widespread inappropriate care denials in Medicare Advantage

    A new HHS Office of the Inspector General report (OIG) highlights serious problems with  denials of care and coverage in Medicare Advantage. As the OIG found in 2018, tens of thousands of people in Medicare Advantage are not receiving the care they need, to the detriment of their health and well-being. The OIG urges the Centers for Medicare and Medicaid Services (CMS) to conduct better oversight of these health plans and alert people to serious Medicare Advantage violations. Last time round, CMS did not heed the OIG’s call. Will it do so this time round?

    People with costly and complex conditions are at particular risk of going without needed care in Medicare Advantage. If their incomes are limited incomes, they are generally at the mercy of their Medicare Advantage plans to cover their care. You are playing Russian Roulette when choosing a Medicare Advantage plan since there’s no way to know in advance whether your plan will pay for the care you need.

    Better oversight and warnings about Medicare Advantage are critical, but they are not nearly enough. Most people are locked into Medicare Advantage after they initially enroll. They are hard-pressed to switch to traditional Medicare because they need supplemental coverage to fill its coverage caps, which is often hard to come by. Insurers are only required to offer supplemental coverage when people are first eligible for Medicare, when they have been in a Medicare Advantage plan for no more than 12 months, and in other very limited circumstances.

    One key concern with Medicare Advantage plans, highlighted by the OIG, is that they are paid a flat fee each month, regardless of the amount they spend on care, creating a powerful incentive for them to deny care in order to maximize profits. Unsurprisingly, every year CMS finds “widespread and persistent problems related to inappropriate denials of services and payment.”

    The OIG found that nearly one in seven (13 percent) Medicare Advantage prior authorization denials were inappropriate. Medicare Advantage plans frequently denied requests for care that met Medicare coverage rules. Consequently, enrollees often could not get the medically necessary care their doctors prescribed, or their access to care was delayed.

    Prior authorization requirements create administrative barriers to care for people enrolled in Medicare Advantage. Inappropriate denials can result in enrollees having to pay for care that Medicare should be covering. Worse still, inappropriate denials can jeopardize the health and well-being of enrollees. But, the government won’t let you know if you’re enrolled in a Medicare Advantage plan that routinely wrongly denies you needed care, much less warn you against enrolling in Medicare Advantage plans that routinely wrongly deny care.

    Prior authorization denials are numerous, totaling 1.5 million in 2018 alone, according to the OIG. And, many physicians say that some, if not many, of the prior authorization requirements Medicare Advantage plans impose are not medically justified and out of line with Medicare coverage rules. To date, CMS has not prevented them.

    It’s often the most expensive services that Medicare Advantage plans inappropriately deny. That’s where they can increase their profits most. Consequently, people in Medicare Advantage are less likely to benefit from inpatient rehabilitation services and skilled nursing services after a hospitalization. They are also less likely to have coverage for MRIs.

    The OIG found that the lower cost alternatives to nursing and rehab care that Medicare Advantage plans were willing to cover for their enrollees were not adequate to meet enrollees’ needs. Similarly, delays of testing hurt patients. Here’s just one case example the OIG highlighted of an MA (MAO) inappropriate denial:

    “Case D421: MAO delayed a CT scan by 5 weeks for a beneficiary with cancer. An MAO denied a request for a CT scan of the chest and pelvis for a beneficiary with endometrial cancer. The provider was able to get the denial reversed 5 weeks after the initial request by submitting additional information and filing an appeal. However, our physician panel determined that the original request had sufficient documentation to demonstrate that the CT was needed to assess the stage of the cancer and to determine the appropriate course of treatment. Delayed care can negatively affect beneficiary health, particularly for urgent conditions. Our physician reviewer noted the importance of timely monitoring the growth and extent of cancer to assess severity of the disease and determine the course of treatment.”

    Here’s more from Just Care:
  • Prior authorization: How dangerous is it?

    Prior authorization: How dangerous is it?

    Health insurers argue that requiring prior authorization before you receive certain services–approval for particular treatment–allows them to better manage your care. In fact, prior authorization requirements often lead health insurers to delay your receipt of care and can jeopardize your health. Traditional Medicare does not require prior authorization for medical services, but Medicare Advantage plans do, as do all commercial health insurers. What are the dangers of prior authorization?

    Prior authorization requirements give health insurers the ability to come between you and your treating physician to decide whether the care your doctor recommends is medically reasonable and necessary. Too often, health insurers take their pretty time in deciding whether they will cover the care treating physicians recommend. And, if it’s a specialty procedure, the person deciding often has no specialty expertise. That health insurer employee might even have a financial incentive to delay or deny your care.

    Lola Butcher reports for Medscape on one oncologist who believes prior authorization requirements resulted in the death of his patient. In that case, the health insurer refused to approve a PET scan when the oncologist initially sought authorization for it. The insurer came between this physician and his patient, delaying the patient’s care and allowing more time for the patient’s cancer to spread.

    The oncologist fought the health insurer’s denial of the PET scan, insisting that it was standard care for a patient in his condition. During the more than three weeks it took the doctor to get the insurer to approve the procedure, the patient was hospitalized because his symptoms grew worse.

    Unfortunately, inappropriate denials resulting from prior authorization are not uncommon. Inappropriate delays of three to four weeks or more while physicians argue with the health insurer, are also not uncommon. And, physicians say that insurers are using prior authorization requirements for medical procedures and prescription drugs more often.

    There are two sides to the prior authorization story. Prior authorization could keep doctors who are not following standard protocols from providing improper treatments. But, do they do more harm than good?

    To complicate matters, there’s no way to know what medical protocols health insurers are following when they deny coverage for a procedure. Unlike other countries that set the medical protocols for private health insurers, our government allows insurers’ medical protocols to be proprietary. Yet, these protocols can result in people not getting needed care in a timely manner. Health insurers have a financial incentive to delay and deny care inappropriately as the less money they spend on care the more they profit.

    One doctor reports that he tried to prescribe a patient who had an infection the standard drug for the standard 10-14-day course of treatment. But, the insurer would only authorize the drug for five days, even though there is no data to suggest five days is adequate.

    Another doctor reports that a patient of his needed an ultrasound and MRI twice a year to monitor her for breast cancer, as she was at high risk, testing positive for the BRCA gene and with a family history. But, the insurer has required him to get prior authorization each time his patient needs the procedures. This takes up a lot of his time for no legitimate reason. Her medical history is not changing.

    The stories of inappropriate delays caused by prior authorization requirements are seemingly endless. And, they happen even when patients are in emergency situations. It’s not every health insurer, but reports suggest that it’s a significant proportion of them. People have no clue which health insurers to avoid.

    Sometimes insurers require patients to get particular tests before they can get a procedure. The problem is that a negative test result might not indicate that the patient does not need the procedure. One specialist explains that the MSLT is often wrong as a measure for whether a patient suffers from narcolepsy. But, some insurers require it in place of the treating physicians’ expert opinion, undermining their patients’ care.

    Appealing wrongful insurance company denials also can be extremely time-consuming.

    Some states are finally intervening. Texas, for example, does not permit health insurers to require physicians to seek prior authorization if the physicians have met the insurers’ medical necessity criteria at least 90 percent of the time in the past six months. In Illinois, a new law limits the number of services for which insurers can require prior authorization and mandates that insurers make a determination within five days.

    The US Congress is also considering bi-partisan legislation to protect people from some of the burdens of prior authorization. It focuses on limiting the use of prior authorization by Medicare Advantage plans and requiring Medicare Advantage plans to make real-time coverage decisions in certain cases, as well as to have an electronic prior authorization process.

    Here’s more from Just Care:

  • Health care coverage denied? Appeal, it’s easy

    Health care coverage denied? Appeal, it’s easy

    In its infinite wisdom, Congress is eyeing a fix for people with poor health insurance whose health care is wrongly denied or delayed. No, it’s not guaranteeing everyone good health insurance. It’s not even ensuring that health insurers pay claims appropriately and in a timely manner. Rather, CNBC reports that some Democrats in Congress want to give people the right to sue their health insurance company.

    If you have Medicare, you already have the right to appeal denials of care. Most people don’t realize they can or that it’s worth the time, so only about 1 percent of people appeal. But, more than 75 percent of appeals result in coverage, according to the Office of the Inspector General. And, appealing a denial of care or coverage is easy and free. You don’t need a lawyer.

    To appeal, simply send a letter from your doctor justifying the need for a medical service to the address on your Explanation of Medicare Benefits form or your Medicare Advantage form and request the appeal.

    That said, if you want to sue your health insurance company in federal court because it denied your claim or it’s not paying your medical bills in a timely fashion, chances are you can’t. Some Democrats want to change that. 

    Health insurers generally write their contracts to require arbitration of coverage disputes. They prevent class action lawsuits. Arbitration protects health insurers because decisions are neither open to public scrutiny nor easy to appeal. Arbitration keeps the health insurers from being accountable for their bad acts.

    Congresswoman Katie Porter, D-Calif. proposes the Justice for Patients Act, which would prevent health insurers from requiring arbitration. It would allow individual and class action lawsuits if patients preferred to go that route.

    Lawsuits might help to hold health insurers accountable. Patients rarely win money in arbitration disputes, according to the Economic Policy Institute. Fewer than one in ten arbitration disputes lead to financial rewards for patients.

    So long as corporations can require consumers to engage in arbitration, they will. Porter’s bill focuses exclusively on permitting lawsuits against health insurers. But, arbitration is required in all kinds of discrimination, sexual harassment and civil rights cases. People should have the right to sue corporations. Corporations have little to fear if their behavior is not egregious. The costs are steep enough and the time involved prolonged enough that lawsuits will never become the first line of attack.

    Here’s more from Just Care:

  • Well-kept secrets of Medicare Advantage plans

    Well-kept secrets of Medicare Advantage plans

    In the last few weeks, I’ve given a couple of talks focused on Medicare Advantage. I always highlight the biggest well-kept secrets of Medicare Advantage plans, summarized below. They should give anyone thinking of joining a Medicare Advantage plan pause.

    Believe me, I realize that traditional Medicare is unaffordable for many people because it lacks an out-of-pocket cap. That’s an issue Congress needs to fix because traditional Medicare gives people the freedom to choose the care they want from the doctors and hospitals they want to use. Anyone who joins a Medicare Advantage plan loses that freedom and takes a big gamble.

    Insurance is about tomorrow at least as much as today. Not needing much health care now is not a reason to choose a Medicare Advantage plan. When you do, accessing care in an MA plan can be stressful. Inappropriate delays and denials of care are routine, as are restricted and ever-changing networks.

    Medicare Advantage can take a huge financial and emotional toll on you and your family. As long as you’re healthy, you’re fine. If you get sick, it’s impossible to know whether your Medicare Advantage plan will meet your needs. If you’re able to get the care you need when you develop a costly or complex condition, Medicare Advantage can be far more expensive than traditional Medicare. Annual out-of-pocket costs are now more than $7,550 for in-network care alone.

    It’s inhumane and unconscionable for Congress to force vulnerable Americans to take such a large risk with their healthcare in Medicare Advantage. It’s equally wrong to keep people from switching out of Medicare Advantage to traditional Medicare because it lacks an out-of-pocket cap and getting affordable supplemental coverage is not guaranteed.

    MA plans offer insurance that can disappear when you need it

    • They can tempt you with inexpensive things like gym club memberships and low premiums
    • They can tease you by not interfering with routine inexpensive items of healthcare
    • They can arbitrarily deny you access to expensive healthcare your doctors recommend
    • They can arbitrarily restrict and change their provider networks at any time
    • They can arbitrarily change their coverage rules at any time
    • They can change ownership, leadership and behaviors at any time
    • They can leave your community at any time

    MA plans take away your choices

    • They often do not cover care from many of the providers in your community
    • They often do not cover any care at Centers of Excellence
    • They don’t reliably cover the care your doctors think you need
    • They can endanger your health with widespread and inappropriate delays and denials of care
    • They often do not offer high-value care for people with complex conditions; if they do, they don’t make it easy to get, and may not even let you know about its availability
    • They impose out-of-pocket costs for most care and, for people who need expensive care, as much as $7,550 in out-of-pocket costs each year for in-network care alone
    • They do not disclose their mortality rates, denial rates, and average out-of-pocket costs

    MA plans are paid a fixed rate upfront; the less they spend on your healthcare, the more of your money they keep and the more profits they make

    • Their business model prioritizes covering low-cost care over high-value care
    • Their business priorities are to pay for less care and pay less for care
    • To compete effectively and keep their premiums low, they design their plans to avoid enrolling people with complex conditions
    • They lack an incentive to focus on people’s long-term needs or the needs of the community, as they must answer to Wall Street on a quarterly basis.
    • They see money spent on your health as an avoidable expense, not as an investment in our mutual futures
    • They are difficult and costly to oversee
    • They are largely unaccountable for violating their contractual obligations or engaging in fraud

    Here’s more from Just Care:

  • Medicare Advantage gold mine puts traditional Medicare at grave risk

    Medicare Advantage gold mine puts traditional Medicare at grave risk

    Beware of corporate health insurers with eyes on Medicare. To date, these insurers have been taking our money in exchange for offering people benefits through Medicare Advantage plans and then running back to their shareholders with a fat share of their revenue. Healthcare Dive reports that these corporate health insurers have eyes on every Medicare dollar they can get their hands on; they are lobbying heavily for taking over traditional Medicare’s book of business.

    Medicare Advantage plans continue to reap huge profits, so they are expanding into more areas and offering lots of goodies to lure people to enroll. But, what matters most is the quality of the care they are delivering, the costs they are imposing on people with serious health conditions, and the legitimacy of what they are charging for their services. On those issues, we know precious little. What we do know is that government audits over and over again indicate big problems. 

    For sure, these corporate health plans are not competing to deliver high value care to older adults and people with disabilities. They are doing their best to enroll people who are healthy, who don’t use a lot of services, and then claim that some of these people are in need of care coordination in order to reap greater revenue from the Centers for Medicare and Medicaid Services.

    Medicare Advantage plans must have one of the best business models going. They say they are offering people Medicare health care benefits but no one has a clue what that means. We don’t know the extent to which they are pocketing money that should be going towards the health and well-being of people with Medicare or how to hold them to account when they are violating their contracts. What we do know is that many of these plans have high denial rates, some have high mortality rates and others have been found to deliver poor quality care. They are contracting with poorer quality nursing homes and home care agencies to provide services to their members.

    Why Congress would consider giving these corporate health insurers more business is hard to understand if our representatives are putting the interests of their constituents and the national treasury first. Yes, some Medicare Advantage plans are helping people who cannot afford supplemental coverage in traditional Medicare. But, the answer should be to strengthen and improve traditional Medicare, which is far more cost effective and allows people unfettered access to the care they want and need, not to hand more business to corporate health insurers who by at least one recent account are responsible for not meeting their members’ care needs, leading them to die.

    Medicare Advantage plans have a huge bag of tricks to seduce more people to enroll with them in 2021. But, even the Trump administration’s Department of Justice recognizes that at least some of these health insurers are engaging in massive fraud. HealthCare Dive reports a recent DOJ suit against Cigna alleging $1.4 billion in overcharges. There was a suit against Anthem in March and Sutter Health settled a similar fraud suit for $30 million.

    Some might think that these insurers only commit fraud against the government. Keep in mind that these insurers also can profit handsomely by delaying and denying care and creating other administrative and financial barriers to keep people from receiving needed services that Medicare covers. Whether the Medicare Advantage plan you are enrolled in or might be considering switching to does or does not do so is a gamble you should not take lightly.

    Here’s more from Just Care:

  • Medicare Advantage plans offer no real choice

    Medicare Advantage plans offer no real choice

    In the context of health insurance, choice may sound good, but it is a loaded word. The only time any of us has real choice is when we can actually distinguish among our health insurance options and at least one of them guarantees us affordable care from the doctors and hospitals we want to use. For that reason, Medicare Advantage plans, corporate health plans that contract with the government to provide Medicare benefits, offer no real choice.

    Indeed, most Americans, whether working or retired, have no real choice of corporate health insurance plan. And, here, I’m not talking about the fact that employers often give people one choice. It’s that even when you have multiple choices, as you do with Medicare Advantage, you cannot distinguish among them in a meaningful way. And, more important, there’s no evidence that any of them will meet your needs if you get sick.

    Because no one can predict future health care needs, the only health insurance that makes sense is health insurance that will cover us, no matter what care we need. at a cost we can afford. Consequently, the notion that we should pick a health insurance plan that’s right for us is preposterous. Not only do we not know what care we will need down the road, we also do not know what doctors and hospitals we will want to use to treat that care.

    But, no private health insurer is willing or able to guarantee us affordable access to care from the doctors we want to use. Even when premiums are reasonable, deductibles and coinsurance payments can be sky high for people who need a lot of care. In Medicare Advantage, they can be as high as $6,700 a year for medical care alone.

    Private health insurers cannot control costs. What’s equally problematic is that if any one of them offers high-value care for people with costly conditions, everyone with those conditions will join, their costs will rise, and they will not generate the profits they need to survive as a commercial business. So, Aetna, UnitedHealth and others will never promote the quality of care they deliver for people with costly conditions.

    With Medicare Advantage, the good news is that the government pays for a large part of the premium. But, the problem remains that Medicare Advantage plans cannot compete to deliver high-value care to people with costly conditions or they would not survive as businesses. In fact, as should be expected, they do their best to avoid providing care to people with complex health care needs.

    Government audits show “widespread and persistent … performance problems related to denials of care and payment,” and Medicare Advantage plans “threatening the health and safety” of their members. And, though Medicare Advantage plans are required by law to turn over data that would allow the government to know whether they are delivering appropriate levels of care–e.g., enough physical therapy, home care, cancer care–the data the Medicare Advantage plans disclose is unreliable and incomplete.

    Only traditional Medicare, public health insurance, social insurance, guarantees you coverage for reasonable and necessary care from the doctors and hospitals you want to use. And, it reins in provider rates. But, it’s still expensive and requires you to have supplemental coverage to protect yourself from financial risk if you do not have Medicaid or retiree coverage that fills gaps.

    Medicare for all strengthens and improves traditional Medicare, eliminating all premiums, deductibles and coinsurance, so you can go to the doctors and hospitals you want to use without worry about the cost. It covers vision, hearing, dental and long-term care. And, it costs less than our current health care system because everyone is in it. And, private health insurers are out. It reduces administrative costs by $600 billion a year and drug costs by another $250 billion a year.

    If you support Medicare for all, please let Congress know. Please sign this petition.

    Here’s more from Just Care:

  • Do you need care? Why should your health insurer decide

    Do you need care? Why should your health insurer decide

    In a Washington Post op-ed, William E. Bennett Jr., a gastroenterologist and associate professor of pediatrics at the Indiana University School of Medicine, makes the case that health insurers should not be allowed to practice medicine. They too often deny medically necessary care unless and until your doctor is willing to go through hoops with their medical staff. But, medical staff who work for health insurers have no clue whether you need care.

    Bennett appreciates our need for health insurance. He also recognizes that having health insurance is necessary but not sufficient for our well-being. To get his patients needed medicines and tests, he must request prior authorization from his patients’ insurers, which can needlessly delay their access to care for weeks. And, still, the insurers may deny needed care.

    Only if Bennett appeals to a doctor who works for the insurer and says the right key phrases, will the insurer reverse its denial. Most of the time, the doctor in the employ of the health insurer has little accurate information about the patient; the doctor has never had any contact with the patient. Bennet explains that the insurer’s doctor is unqualified to know whether the treatment or medicine is needed.

    There is nothing beneficial about this process for the doctor or the patient. It does not assure the patient gets the proper treatment. In fact, it keeps many patients from getting needed care. And, it burdens the doctor excessively and unreasonably.

    Bennett experiences the system from the patient’s side as well because his daughter has a serious health condition, and he has had to deal with an insurer that has limited her access to needed treatment. Appealing is a challenging process that requires Bennett to rely on the advocacy of his daughter’s doctors. It takes time and does not always work. In the meantime, his daughter suffers, even though his daughter’s treating physicians all know she would benefit from the treatment.

    In short, when health insurer denials are based on the insurer’s claim of lack of medical necessity, the system breaks down, and the most vulnerable patients are harmed. One study revealed that one health insurer denied claims for emergency visits that met a “prudent layperson” emergency coverage standard in more than 85 percent of cases. Patients can appeal the denials with a high likelihood of success on appeal. But, only a tiny number know they can appeal and have the wherewithal to do so.

    Bennet concludes that health insurers should not be able to decide the care people need: “When an insurance company reflexively denies care and then makes it difficult to appeal that denial, it is making health-care decisions for patients. In other words, insurance officials are practicing medicine without accepting the professional, personal or legal liability that comes with the territory.”

    Here’s more from Just Care: