JustCare

Tag: Prior authorization

  • 2025: Government finalizes new Medicare Advantage policies

    2025: Government finalizes new Medicare Advantage policies

    Last Friday, the Centers for Medicare & Medicaid Services (CMS) issued a final rule regarding Medicare Advantage (MA) and Medicare Prescription Drug (Part D) policy. The rule will take effect in 2026. Of note, the final rule does not call for Medicare coverage of Ozempic or other anti-obesity drugs for people seeking to lose weight, as proposed, nor does it put guardrails on insurers’ use of artificial intelligence to deny care.

    CMS chose not to finalize provisions in the Biden Administration’s proposed rule related to promoting equity, ensuring equitable access to MA services, imposing guardrails for artificial intelligence (AI) or covering anti-obesity medicines.

    The rule does require MA plans to cover inpatient hospital admissions that they approved based through a prior authorization process. MA plans have too often decided post prior authorization approval to deny coverage for inpatient admissions that they deemed, after the fact, should have been treated as outpatient admissions. MA plans can only reopen a prior approval of an inpatient admission because of fraud or administrative error.

    CMS also finalized a rule ensuring that enrollees and providers can appeal an MA denial whether it comes before, during or after a procedure.

    CMS finalized a proposal that prohibits Medicare Part D plans from charging a deductible or copay for adult vaccines that the Advisory Committee on Immunization Practices recommends. The deductible also does not apply to insulin products; and, cost-sharing for these products cannot go above $35.

    In addition, Part D plans must allow enrollees to make monthly payments for their covered drugs over the course of the year, rather than in one lump sum at the pharmacy. Effective this year, these payments cannot exceed $2,000 over the course of the year.

    Here’s more from Just Care:

  • Medicare Advantage costs and prior authorization rules impede access to care

    Medicare Advantage costs and prior authorization rules impede access to care

    Medicare Advantage costs and prior authorization rules continue to impede access to care. Anyone enrolled in a Medicare Advantage plan–Medicare coverage administered by a corporate health insurer–should be concerned about whether they will be able to get and afford the care they need if they get sick. Traditional Medicare provides coverage for care from almost any physician or hospital in the US without the need for prior authorization.

    Jakob Emerson reports for Beckers Payer that typical deductibles for Medicare Advantage plans are now more than twice what they were in 2024. It’s fair to assume that they will continue to rise, given the Trump administration’s full court press on government spending. You’ll be fine in Medicare Advantage if you’re healthy, but you’ll likely be far better off in traditional Medicare if you want to ensure you’ll be able to afford and receive the care you need when you get sick.

    Average Medicare Advantage deductibles were about $132 in 2024 and are now $315, according to an eHealth survey. That’s a 139 percent increase. Monthly premiums average just $5 a month this year, down from $9 in 2024. And, total out-of-pocket costs for covered in-network services can be as high as $9,350 this year, depending upon the Medicare Advantage plan.

    Average Medicare Part D prescription drug coverage premiums are also up, from $29 to $36, about 25 percent.

    Meanwhile, prior authorization rules remain another obstacle to care for Medicare Advantage enrollees, particularly those who need costly and complex care. Rylee Wilson reports for Beckers Payer that some states are looking into regulating insurers’ use of prior authorization. They are especially focused on insurers’ use of artificial intelligence or AI to determine whether a procedure should be covered and want a physician to oversee those decisions. (Could  that simply mean a physician rubber-stamping them?)

    Patients are currently suing UnitedHealth and Humana for using AI to deny rehab care in Medicare Advantage inappropriately. UnitedHealth spokespeople argue that they do not use AI exclusively to make coverage decisions. They might not, though having a provider oversee these decisions with financial and other incentives to approve them is no better than using AI exclusively.

    Last year, the Centers for Medicare and Medicaid Services, CMS, which oversees Medicare, issued guidance on the use of AI in Medicare Advantage. CMS did not ban the use of AI or even restrict it. It simply said that the AI algorithm must comply with Medicare’s coverage requirements. Good luck enforcing that rule.

    Dr. Mehmet Oz, who will head of CMS, once confirmed, believes in AI as a tool for expediting prior authorization decisions–seemingly, even though they can speed up inappropriate denials. However, Oz says that insurers should not use AI for more than 1,000 procedures.“I would argue that to use AI wisely, we would make a decision which is we’re only going to pre-authorize 1,000 procedures,” he said at a recent Senate hearing. Where he pulled the 1,000 number from is anyone’s guess.

    Here’s more from Just Care:

  • Medicare Advantage inappropriate denials of care abound

    Medicare Advantage inappropriate denials of care abound

    Just as with restaurants, automobiles and homes, Medicare Advantage plans vary from awful to excellent. But, unlike with restaurants, automobiles and homes, you can’t choose a Medicare Advantage plan knowing it will meet you needs. It’s a total crapshoot. Inappropriate denials of care abound.

    Beware. And take a hard look at your Medicare Advantage plan, if you’re in one. Choosing the wrong Medicare Advantage plan could kill you. A report from a few years ago revealed that if the Centers for Medicare and Medicaid Services cancelled contracts with the five percent of worst performing Medicare Advantage plans, it would save tens of thousands of lives a year!

    To ensure you have access to the care you need when you develop a serious condition or suffer a bad injury, consider switching to traditional Medicare, the government administered program that covers your care from most physicians and hospitals anywhere in the US. You have until the end of March to switch. But, unless you have Medicaid, you will need to be sure you can buy supplemental coverage to fill gaps in traditional Medicare.

    If you stay in a Medicare Advantage plan, be prepared to fight your insurer when you need costly care. CMS not only does not cancel contracts of insurers with high rates of inappropriate denials, it doesn’t tell you which are the worst-performing Medicare Advantage plans.

    Do not assume that a Medicare Advantage plan with a five star rating will meet your needs. The ratings do not factor in inadequate networks or inappropriate denial rates, much less mortality rates. And, while CMS has worked to improve those ratings, the insurers have successfully sued to prevent changes to the ratings. For reasons yet unknown, the Trump administration just dropped a Biden administration appeal of one of those lawsuits.

    If you stay in Medicare Advantage, consider denial rates. The latest report from the Kaiser Family Foundation reveals that CVS and Centene have the highest prior authorization denial rates in 2023. On average, MA plans denied 6.4 percent of prior authorization requests, which might sound reasonable. But, MA insurers use prior authorization predominantly for costly services, which only a small fraction of their enrollees need.

    Centene’s denial rate was 13.6 percent in 2023. CVS Health’s was 11 percent. Typically, denials are overturned 80 percent of the time when appealed. When people appealed Centene’s denials, they prevailed 93.6 percent of the time. Unfortunately, only about 10 percent of coverage denials are appealed.

    Here’s more from Just Care:

  • Medicare Advantage insurers are killing rural hospitals and communities

    Medicare Advantage insurers are killing rural hospitals and communities

    Write-Off Warrior, a research and advocacy firm that supports rural health systems, just released “Preyed On: How Insurance Corporations are Bleeding Rural Hospitals and Communities to Death.” The report documents the many harmful behaviors of large insurance corporations responsible for endangering the health of rural America. The report also highlights the far-reaching consequences for our country if Congress fails to address insurer behaviors driving rural health disparities.

    Rural Americans represent about 20 percent of the US population. They tend to suffer more from chronic conditions than other Americans. But, they struggle more to get the care they need than other Americans and their plight is worsening.

    The authors surveyed 41 rural hospitals in 15 states across the US and found that the biggest problems they faced were burdensome insurer prior authorization procedures, insurers’ second-guessing of treating physicians, and insurers’ long delays and denials of provider payments. Moreover, insurers take advantage of rural hospitals’ weak bargaining power to negotiate excessively low rates or to keep these hospitals from being in-network. Rural hospitals are foundering.

    Medicare Advantage insurers are the biggest threat to rural hospitals and communities, according to 31 of 41 hospital execs surveyed. These corporate insurers have undermined the hospitals’ financial stability. These insurers have led rural hospitals to end important mental health and rehab services. And, these insurers are leading many rural hospitals to shut down altogether.

    While the top six Medicare Advantage insurers profited to the tune of $41.7 billion in 2023 alone, Medicare Advantage enrollees continue to face rising costs, notwithstanding these insurer practices. They also are often forced to travel long distances for care. Congress must recognize that Medicare Advantage does not work for rural Americans and reform the system.

    Until Congress reforms the Medicare Advantage program to meet the needs of rural Americans, insurers will profit more at the expense of rural communities. Nearly 200 rural hospitals have closed in the last 2o years. And, more than 700 are at serious risk. These hospital closures put rural America on life support.

    Without vibrant rural communities and good rural health, critical food and energy production, vital to the entire country, are at risk of failing.

    Here’s more from Just Care:

  • Oncologists report excessive deaths from prior authorization

    Oncologists report excessive deaths from prior authorization

    A new survey from the American Society of Radiation Oncology illustrates the dangers of prior authorization. Prior authorization kills an “inordinate number” of people and harms others. Insurers often deny care to the detriment of patients when physicians first ask for authorization; when denials are appealed, insurers then approve care the vast majority of the time.

    About 225 of the 750 radiation oncologists polled reported adverse health outcomes from prior authorization.  Their patients ended up in the emergency room or hospitalized or with a permanent disability. One in fourteen of the oncologists polled said that one or more of their patients had died as a result of prior authorization.

    Prior authorization can have benefits, particularly in cases in which physicians are not well trained. Prior authorization can ensure physicians are treating patients appropriately, based on evidence. Prior authorization can also keep costs down.

    But, insurers use prior authorization without regard to its effects on quality of life for patients. And, while prior authorization can help protect against unnecessary treatment, there is no one protecting patients from insurers that use prior authorization inappropriately, in ways that harm patients.

    The oncologists polled suggested insurers’ use of prior authorization is only increasing. Moreover, it increases staff burnout.

    • More than nine in ten oncologists (92 percent) reported treatment delays from prior authorization and nearly seven in ten (68 percent) reported delays of at least 5 days;
    • More than eight in ten oncologists (82 percent) blamed prior authorization for patients receiving less than the best care;
    • Nearly six in ten (58 percent) oncologists said prior authorization kept them from following recommended guidelines;

    Those polled made clear that it’s critical to appeal prior authorization denials because more than 70 percent are reversed on appeal. But, patients and physicians sometimes do not have the resources to appeal. In some instances, the tradeoffs of appealing care denials, in terms of time spent, means physicians are unable to do their jobs.

    Moreover, insurers still have 72 hours to review an expedited appeal. For some patients with health insurance, the harm from such a delay is significant.  One doctor said that in that time, “I’ve had patients who’ve literally had a tumor growing out of their chest. Waiting 3 days for an appeal means there’s more cancer to treat, even just in the time between when I made the plan for them initially, and when I actually get to start their treatment. Sometimes it means the plan has to change because the tumor has gotten that much bigger in that time period. Every day matters.”

    Insurers shouldn’t be allowed to continue doing prior authorization for treatments that are virtually always approved on appeal.

    Here’s more from Just Care:

  • Will UnitedHealth stop denying care inappropriately or simply deny doing so?

    Will UnitedHealth stop denying care inappropriately or simply deny doing so?

    Shareholders at UnitedHealth are proposing that the company study and report publicly on the financial and public health consequences of its policies that lead to delays and denials of health care. These shareholders want people to vote on their request at UnitedHealth’s annual meeting, reports Rylee Wilson for Becker’s Payer.

    Specifically, the shareholders want UnitedHealth to report on the frequency of delays of care and foregone care, as well as harm to patients, resulting from UnitedHealth’s prior authorization requirements. Put differently, they want the company to disclose how its prior authorization requirements affect access to treatment.

    UnitedHealth claims it will respond to these shareholders once it schedules its annual meeting in June. The shareholders, represented by the Interfaith Center on Corporate Responsibility, represent more than 300 institutional investors. (UnitedHealth has more than 5,000 institutional investors.)

    The shareholders argue that these inappropriate delays and denials might boost short-term profits, but they risk hurting the UnitedHealth brand.

    Wendell Potter, head of the Center for Health and Democracy, explains that the inappropriate care denials harm more than patients. UnitedHealth defends its behavior saying that it pays 90 percent of claims, which might be true. The problem is that the 10 percent of claims it denies are often for coverage of expensive life-saving or otherwise critical care.

    Meanwhile, UnitedHealth is poised to announce big year-end profits. Some say UnitedHealth will have more than an eight percent year-over-year earnings growth. Fourth-quarter earnings are projected to be about $6.72 a share. If so, it would be a 9.1 percent increase from last year’s fourth quarter.

  • New physician survey finds prior authorization harms cancer patients

    New physician survey finds prior authorization harms cancer patients

    Here’s yet another reason to opt for traditional Medicare over insurer-run Medicare Advantage plans. A new survey by the American Society for Radiation Oncology (ASTRO) finds that insurers’ use of prior authorization can harm cancer patients, reports Renal+Urology News. Prior authorization also makes it hard for oncologists to do their job.

    Your insurance plan should provide good coverage for you today and in the future, whatever your health care needs. Sadly, as we get older, it becomes increasingly likely we will be diagnosed with cancer or some other serious health conditions. So, it’s not wise to gamble with your health insurance.

    According to the 754 oncologists surveyed in the last few months, in more than nine and out ten (92 percent) instances, prior authorization means that patients don’t get care as quickly as they otherwise could. Consequently, about one in ten patients end up forgoing treatment. Some patients end up in the ER or the hospital. Some end up with disabilities, which can be permanent. And, seven percent of respondents said that their patients died.

    More than half of patient radiation oncology services require prior authorization, even though insurers approve them more than seven in ten times initially. On appeal, nearly three quarters of denials are approved.

    Nearly six in ten (58 percent) physicians surveyed said that prior authorization kept them from being able to follow treatment protocols. More than eight in ten (82 percent) said that in some cases they ended up providing their patients with less good treatment as a result of prior authorization.

    Not only can prior authorization seriously harm patients’ primary treatment, it can also prevent them from or pose a significant barrier to their receiving treatment for side effects. For example, they might not be able to get pain or antinausea medicines.

    According to respondents, insurers are ramping up prior authorization requirements, not easing them. A typical delay is at least five days. It also requires more administrative staff.

    Howard M. Sandler, MD, chair of the ASTRO board of directors, sums up the survey findings: “These survey findings confirm what radiation oncologists witness daily: prior authorization policies are failing people with cancer, causing avoidable delays that are dangerous and, in too many cases, deadly.”

    Here’s more from Just Care: 

  • Proposed Medicare Advantage rule aims to limit bad insurer behavior

    Proposed Medicare Advantage rule aims to limit bad insurer behavior

    Last week, the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, proposed a new rule intended to limit some of the many insurance company bad acts, reports Rebecca Pifer for HealthcareDive. Unfortunately, Medicare Advantage plans all too frequently inappropriately delay and deny people’s care notwithstanding CMS rules. To protect MA enrollees, the government should penalize insurers who violate their obligations severely enough to deter bad acts; without strict penalties, more rules are unlikely to be of much help.

    The CMS proposed rule strives to address five of the biggest concerns with Medicare Advantage. The Trump administration will have the power to decide which, if any, of these proposals will be finalized.

    • Insurers’ use of artificial intelligence to deny care without consideration of patient needs. The rule is designed to make transparent to MA enrollees their insurers’ coverage policies. Insurers sometimes use artificial intelligence to engage in across-the-board denials of care, even when care is urgently needed. The  MA insurers use AI particularly to deny care for people with costly and complex conditions, such as people with cancer and people needing rehabilitation services. New CMS data reveals that more than 80 percent of denials are overturned on appeal, but only four percent of people appeal. The proposed rule also would require insurers to notify enrollees about their appeal rights.
    • Insurers’ publication of inaccurate provider directories that misrepresent which physicians and hospitals are in network. The rule strives to ensure that the provider directories do not mislead enrollees as they are wont to do.
    • Insurers’ misleading marketing. The rule strives to protect enrollees from misleading marketing.
    • Insurers’ coverage of supplemental benefits. The rule aims to ensure that enrollees are fully aware of these benefits and their limitations.
    • Insurers’ reporting of how much money they spend on patient care rather than administration and profits. Insurers are legally required to spend at least 85 percent of the money they are paid to cover enrollees on patient care. But, many appear to find ways to spend a lot less.

    In addition, if finalized, the proposed rule would for the first time require Medicare to cover weight-loss drugs for people who are obese, even if they don’t have other health conditions.

    Here’s more from Just Care:

  • Senate investigation shows high Medicare Advantage denial rates for costly care

    Senate investigation shows high Medicare Advantage denial rates for costly care

    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:

  • It’s Medicare open enrollment season, here’s what to do and not do

    It’s Medicare open enrollment season, here’s what to do and not do

    During this Medicare Open Enrollment period between October 15 and December 7, here’s what to know:
    • People on limited incomes can’t make a meaningful Medicare choice.
    • Only Traditional (Original) Medicare gives you the freedom to receive the care you need from the doctors and hospitals of your choice. But it lacks an out-of-pocket cap, so it comes with financial risk unless you also have supplemental coverage, which can be expensive. 
    • Medicare Advantage is always a gamble. MA plans can overrule your doctor and deny you the care you need.
    If you can’t afford Traditional Medicare, call your member of Congress and tell them to add an out-of-pocket cap. 

    Whether you’re in Traditional Medicare or a Medicare Advantage plan, your Medicare Part B premiums will increase and your Part D prescription drug coverage will change in 2025. You should compare your prescription drug Part D options. And, you should be aware that sometimes it is less costly to get your drugs from Costco or another low-cost pharmacy than to get them through your Part D insurance.

    To ensure you get covered for the care you need from the doctors and hospitals you want to use, without administrative hurdles, make sure you are enrolled in Traditional Medicare, the government-administered Medicare program.Only Traditional Medicare gives you the freedom to receive the care you need from the doctors and hospitals of your choice. Unlike Medicare Advantage, Traditional Medicare allows you and your treating physician to decide the care you need without second-guessing. And, with supplemental insurance you have few if any out of pocket costs. But because TM lacks an out-of-pocket cap, millions of Americans can’t afford it.

    If you cannot afford Traditional Medicare or you cannot get supplemental coverage to fill coverage gaps, you have no choice but to enroll in Medicare Advantage. Medicare Advantage is always a gamble. You cannot make a meaningful choice of a Medicare Advantage plan. MA plans can overrule your doctor and deny you the care you need. Reports show widespread and persistent delays and denials of care and coverage in many MA plans. You cannot avoid that. The best you can do is pick a plan with a five-star rating and hope you don’t get sick.

    Don’t assume that anything about your Medicare Advantage plan will remain the same in 2025. Your physicians and hospitals could be leaving the network. Your costs could be rising. Your prescription drug coverage could be changing. Review all your Medicare options carefully, including Traditional Medicare.

    How to choose a Medicare Advantage plan? You can’t make an informed choice or avoid bad actor MA plans.You can’t know in advance whether an MA plan is engaged in widespread and persistent inappropriate delays and denials of care, as many of them are. The government cannot protect you from Medicare Advantage bad actors that do not cover your Medicare benefits, as required. The best you can do is pick a plan with doctors and hospitals you want to use in its network and hope they don’t leave. You can’t count on them staying. This year alone, dozens of health systems have canceled their Medicare Advantage contracts, further restricting access to care for their patients in MA, because MA plans make it hard for them to give people needed care. Unfortunately, in Medicare Advantage, you are gambling with your health care and could incur thousands of dollars in out-of-pocket costs. Insurers have a financial incentive to deny care; the less care they cover, the more they profit. Don’t be seduced by “extra” benefits, which are often very limited and can come with high out-of-pocket costs.

    Keep in mind that when you need costly and complex care, your Medicare Advantage plan is likely to require prior authorization and could overrule your treating physician, denying you coverage. You can appeal, but you might need to pay out of pocket for the full cost of your care. Even when Medicare Advantage plans approve your care, they generally force you to go through hoops and face delays before they will cover your care.

    Don’t trust an insurance agent’s advice about your Medicare options. Unfortunately, insurance agents are paid handsomely to steer you away from Traditional Medicare and into a Medicare Advantage plan, even if it does not meet your needs. You can’t know whether you can trust an insurance agent.

     If you have Medicare and Medicaid:

    • You will have much easier access to physicians and inpatient services in Traditional Medicare than in a Medicare Advantage plan if you need costly health care services or have a complex condition. And, you will have no out of pocket costs.

    For free independent advice about your options, call the Medicare Rights Center at 1-800-333-4114 or a State Health Insurance Assistance Program (SHIP).

    Here’s more from Just Care: