Medicare Advantage Criticism Grows

Hospitals and healthcare advocates have been sounding the alarm about an increase in Medicare Advantage (MA) plans (private-sector alternatives to traditional Medicare) denying claims, delaying payments, and taking too long to review requests to authorize care — creating significant barriers for patient access.

In recent weeks, dialogue around problematic practices involving MA plans has continued to increase with criticism reflecting the challenging experiences caregivers and patients are seeing here in Connecticut.

Latest Advocacy

U.S. Senator Ron Wyden (D-Ore.), U.S. Representative Frank Pallone, Jr. (D-N.J.), and U.S. Representative Richard Neal (D-Mass.) recently wrote a letter to Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure, urging her to use every tool at her disposal to rein in Medicare Advantage plans.

In their letter, the members of Congress noted that MA prior authorization denial rates have “skyrocketed” and called on CMS to conduct greater oversight to ensure the rules CMS has put into place to ensure MA plans mirror the actions of traditional Medicare are being followed.  They also criticized the marketing of MA plans, noting cases in which seniors and people with disabilities are being driven to enroll in plans that don’t meet their needs and the spreading of false information about what certain plans include.  For example, they pointed to a Senate Finance Committee investigation that found that more than 80% of the listed, in-network, mental health providers in a sample of MA plans were “ghosts” — meaning they were either unreachable, not accepting new patients, or not in-network.

Senate Investigations Subcommittee Report

The letter follows a report released October 17, 2024 by the Senate Homeland Security Committee’s investigative subcommittee scrutinizing some of the nation’s largest Medicare Advantage insurers for their use of prior authorization and high rates of denials for certain types of care.

U.S. Senator Richard Blumenthal (D-Conn.) blasted Medicare Advantage providers after the release of the report, criticizing the denial of coverage for certain services through prior authorizations. 

The report found that between 2019 and 2022, UHC, Humana, and CVS denied prior authorization requests for post-acute care at far higher rates than other types of care.  The report also found increases in post-acute care service requests subjected to prior authorization and denial rates for long-term acute care hospitals, among other findings.

Office of Inspector General Report

A report released October 24, 2024 by the Office of Inspector General (OIG) found that MA insurers could be using health risk assessments and chart reviews to inflate payments from Medicare through upcoding.

Insurers received an estimated $7.5 billion in Medicare Advantage risk adjustments for 2023 through health risk assessments and related medical record reviews, the report found.  OIG said the lack of any other follow-up visits, procedures, tests, or supplies for these diagnoses in the MA encounter data raises concerns that either the diagnoses are inaccurate, thus the payments are improper, or MA enrollees did not receive needed care for serious conditions.

State Study

In 2023, Governor Ned Lamont and Connecticut hospitals collaborated on the development of a package of health-related legislative policies aimed at reducing healthcare costs for Connecticut families and improving the delivery of care in the state.  The package included studying how MA plans operate in the state and the impact on healthcare costs, including reviewing how MA administrative processes affect access to and the delivery of care to patients and payments to healthcare providers.  The report is due no later than January 1, 2025.

Connecticut hospitals continue to advocate for policies that ensure patient access to care is protected and not delayed by harmful practices.