Latest News on the Medicare Advantage Program

More Texans enroll in Medicare Advantage but plans often deny necessary care

More Texans are enrolling in Medicare Advantage plans, which are marketed to offer more services at a lower cost than the traditional service payment plan known as Medicare Part B. But a new federal report indicates that this may not be true.

About 2.1 million jeans are enrolled in Medicaid Advantage plans. That’s about an 80 percent increase from the 1.2 million in 2016, when the Medicare and Medicaid Centers first began publishing Medicare Advantage data online.

This may seem like a good thing, especially in Texas, where one in six people do not have health insurance. But plans like these can leave older Americans, many of them with fixed incomes, with surprise medical bills.

Medicare Advantage is offered by private Medicare-approved companies. The plans, which combine different parts of Medicare, charge modest premiums, but are funded primarily by the federal government. They function as HMOs or PPOs, benefiting from controlling costs. They typically require patients to stay online to avoid additional charges, as well as require prior approval of some prescription services, medications, and procedures.

A report from the Office of the Inspector General of the Department of Health and Human Services released in April found that Medicare plans denied the necessary care claims that should be covered by the program. Investigators examined more than 12,000 cases in which the insurer denied payment for services the investigators deemed medically necessary. About 13 percent of those denials met Medicare coverage rules. In other words, it would have been covered by government Medicare Part B.

Not only federal agencies raised concerns about this practice. The American Hospital Association wrote in a statement that Medicare Advantage organizations may be taking advantage of prior authorization, the process of approving a procedure or prescription as medically necessary before the insurer covers it.

“Patients are often blinded by denials and, as a result, may face unexpected medical bills,” the statement said. “The extensive approval process that doctors and nurses have to go through adds billions of dollars lost to the health care system and contributes to the depletion of doctors.”

The Inspector General’s report also notes that such denials disproportionately harm people who cannot afford to pay for their care without insurance, as well as critically ill people who may suffer more from the delay or denial of care. attention.

Experts have also said that the financial stress of medical costs and debt can reduce the quality of life, especially for those suffering from chronic diseases.

The report’s authors recommended that the Medicare and Medicaid Centers update their audit protocols and publish new guidelines on how Medicare Advantage organizations should determine if something is medically necessary. CMS said it would adopt the recommendations.

This is not the first time

The April report is not the first time that Medicare Advantage has been found to have unduly denied payment for certain services. In 2018, the Office of the Inspector General released a report with similar conclusions.

The 2018 report found that when patients and providers appealed for denials of payment, Medicare Advantage organizations overturned 75 percent of their own denials from 2014 to 2016, or approximately 216,000 denials. every year.

“The high number of canceled denials raises concerns that some Medicare Advantage recipients and providers were initially denied services and payments that should have been provided,” the report states. “This is especially worrying because beneficiaries and providers rarely used the appeals process, which is designed to ensure access to care and payment.”

The inspector general recommended that Medicare and Medicaid Centers “improve their oversight” of Medicare Advantage contracts, write letters to Medicare Advantage companies with high denial rates, and make sure enrollees have information about Medicare Advantage violations.

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