Letter: Medicare Advantage Plans Often Wrongly Deny Payment and Prior Authorizations | Letters

To the Editor: When you opt for Medicare Advantage (MA) instead of traditional health insurance, you put decisions about your health in the hands of a big, profit-minded insurance company. Three-quarters of the MA business is currently in the hands of six major insurers: Humana, CVS, Anthem, Kaiser Permanente, Centene and Cigna [https://www.axios.com/2022/01/19/medicare-advantage-2022-enrollment-unitedhealth-humana].

Because of “the potential incentive for Medicare Advantage Organizations (MAOs) to deny beneficiaries access to services and deny payments to providers in an effort to increase benefits,” the agency’s inspector general Health & Human Services just reviewed the performance of MA insurers [https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf]. The results were not good. Of the pre-approval requests that MA insurers denied, 13% should have been approved. Of the denials by MA insurers, 18% were improper under both Medicare rules and the MA insurer’s own rules. Some inappropriate decisions have been reversed by insurer MA, but this often only happened after “a beneficiary or provider appealed or challenged the denial”.

The three causes of these abusive denials:

• Using clinical criteria that Medicare does not impose

• Request unnecessary documents

• Errors in manual review or carrier system

Since every abusive denial saves the insurance company money, you have to wonder how intentional this irregularity rate is. Since every wrongful denial is a hardship on a patient and/or medical provider, you have to wonder how the government can allow this type of behavior, while allowing MA insurers to tout the MA program as a gift of God to the elderly.

The government also knows that MA insurers are also manipulating the system to increase the amount of money they receive from Medicare. [https://www.kff.org/medicare/issue-brief/higher-and-faster-growing-spending-per-medicare-advantage-enrollee-adds-to-medicares-solvency-and-affordability-challenges/]a fiasco that certainly testifies to the money that these insurers devote to “shaping” the opinion of regulators.

It will get worse. Ideas similar to those underpinning the Medicare Advantage program underlie Medicare’s new craze for “value-based care.” The agency recently announced that all Medicare beneficiaries should participate in value-based care programs by 2030. [https://innovation.cms.gov/strategic-direction-whitepaper].

Lee Russ

Bennington, May 7

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Elaine R. Knight