Over the last several decades, US hospitals, particularly the for-profit hospitals, generally have not been the best of allies with the organizations representing people with Medicare and other Americans. But, when it comes to Medicare Advantage, the hospitals continue to speak out vociferously against corporate health insurers for delaying and denying critical treatment and failing to pay the hospitals appropriately for the care they deliver. The Federation of American Hospitals, which represents the for-profit hospitals, is now asking the Centers for Medicare and Medicaid Services (CMS) to evaluate Medicare Advantage plans based on how frequently their prior authorization denials are overturned, reports Rylee Wilson for Becker’s.
The star-rating system for evaluating Medicare Advantage plans is a farce. Medicare Advantage plans with five-star ratings could still have high denial and delay rates. The system misleads people. The star-rating system should be an important measure for assessing Medicare Advantage plans. If CMS’s star-rating system gave substantial weight to Medicare Advantage plan denial and delay rates as well as overturn rates for prior authorization denials, it could help warn people about poor performing health plans.
The Federation of American Hospitals shared its proposal to CMS with Becker’s but does not appear to have posted it online. It argues that adding prior authorization denial overturn rates as a measure in its Medicare Advantage star-ratings system “will enhance CMS’s oversight of MA plans’ denial of prior authorization and payments and provide beneficiaries with needed insight to inform their decision-making.”
Of course, adding prior authorization denial overturn rates as a measure is only as valuable as the data CMS collects is accurate and timely. Right now, CMS does not get complete, accurate or timely data from the Medicare Advantage plans. Without a complete overhaul in how CMS collects data–prior authorization denials should go to CMS at the same time as they go to providers–it’s not clear that this new measure will help Medicare enrollees or enhance CMS oversight.
The Medicare Payment Advisory Commission reports that 80 percent of prior authorization denials were ultimately approved on appeal in 2021. The Federation of American Hospitals argues that this high overturn rate shows that insurers are “intentionally” denying and delaying needed care.
Many members of Congress are also concerned about prior authorization denials and want MA plans to report more data.
Because insurers know that they can maximize their profits through delays and denials of care and coverage and can do so with near impunity, it appears that inappropriate delays and denials are on the rise. And, hospitals are cancelling their contracts with MA insurers to protect themselves and their patients. CMS has not addressed this issue effectively to date.
People enrolled in Medicare Advantage plans should beware, especially given the likelihood that they will face these obstacles to care when they develop a complex or costly conditions.
Here’s more from Just Care:
- AHA warns Medicare oversight agency about dangers of Medicare Advantage
- AHA underscores dangers of Medicare Advantage, need for greater accountability
- Medicare Advantage: Denials and more denials, some deadly
- Underpayments lead hospitals and specialists to cancel Medicare Advantage contracts
- Well-kept secrets of Medicare Advantage plans