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Patients and Doctors Denied Claims and Payments through Medicare Advantage

— October 22, 2018

Patients and Doctors Denied Claims and Payments through Medicare Advantage

The inspector general at the Department of Health and Human Services has found Medicare Advantage plans have been unlawfully denying many medical claims and payments to both patients and physicians.  The private plans insure more than 20 million people (more than one-third of all Medicare beneficiaries) and they have an incentive to deny claims “in an attempt to increase their profits,” according to the report issued.

“An [Medicare Advantage organization] that inappropriately denies authorization of services for beneficiaries or payments to health care providers, may contribute to physical or financial harm and also misuses Medicare Program dollars that CMS paid for beneficiary healthcare,” the report further stated.

“Because Medicare Advantage covers so many beneficiaries, even low rates of inappropriately denied services or payment can create significant problems for many Medicare beneficiaries and their providers,” said inspector general, Daniel R. Levinson.  Additionally, investigators found “widespread and persistent problems related to denials of care and payment in Medicare Advantage.”

Photo by Claudia van Zyl on Unsplash

While few people appeal the denial of claims, about 75 percent of appeals are successful, and federal officials predict that enrollment in Medicare Advantage plan enrollment will jump to 22.6 million, or 36 percent of beneficiaries, in 2019.  The total number of people covered by Medicare is expected to reach 72 million by 2025.

Ana Gupte, a health care analyst at Leerink Partners, said that “one in two American seniors will be in Medicare Advantage by 2021, given the industry-friendly rate and tax policies of the Trump administration.”  The administration approved a big increase in payments to private plans for 2019, indicating it was “committed to unleashing and strengthening the Medicare Advantage program.”

The plans offer extra benefits, which could include transportation to the doctor’s office, home delivery of cooked meals and wheelchair ramps.  However, currently, they can also cause some setbacks.  “Patients may be encountering barriers to timely access to care that are caused by onerous and often unnecessary prior authorization requirements,” said a letter sent to the Trump administration this month by a bipartisan group of more than 100 lawmakers.

Matt Eyles, the president and chief executive of America’s Health Insurance Plans, countered that they “protect patients from unnecessary and inappropriate care” and help reduce costs.

Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, said, “We think it’s very important for our beneficiaries to make the choices that are going to work best for them.” She added, “We are not steering any Medicare beneficiary anywhere.”

Medicare plans receive fixed monthly payments from the government.  If they keep patients healthy, they can often keep costs below what they are paid by Medicare.  However, denying services can also keep down costs.  When a health plan refuses to authorize a service, the beneficiary may go without it. And when doctors are denied payment for services provided, they sometimes try to bill patients.

Health plans cited for serious violations of Medicare rules “can still receive high star ratings” and the bonus payments that go along with high grades, the inspector general warned.  “Some Medicare Advantage beneficiaries and providers were denied services and payments that should have been provided,” he concluded.  Beginning in 2019, “audit violations will no longer be reflected in star ratings.”  A new rating plan will give additional weight to patients’ experiences, as reported by the beneficiaries themselves.


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