Report: Medicare Advantage plans often deny needed care

18% of legitimate claims in 2019 were denied by program.

Every year, tens of thousands of people enrolled in private Medicare Advantage plans are denied necessary care that should be covered under the program, federal investigators concluded in a report published Thursday.

The investigators urged Medicare officials to strengthen oversight of these private insurance plans, which provide benefits to 28 million older Americans, and called for increased enforcement against plans with a pattern of inappropriate denials.

Advantage plans have become an increasingly popular option among older Americans, offering privatized versions of Medicare that are frequently less expensive and provide a wider array of benefits than the traditional government-run program offers.

Enrollment in Advantage plans has more than doubled over the past decade, and half of Medicare beneficiaries are expected to choose a private insurer over the traditional government program in the next few years.

The industry’s main trade group claims people choose Medicare Advantage because “it delivers better services, better access to care and better value.” But federal investigators say there is troubling evidence that plans are delaying or even preventing Medicare beneficiaries from getting medically necessary care.

The new report, from the inspector general’s office of the Health and Human Services Department, looked into whether some of the services that were rejected would probably have been approved if the beneficiaries had been enrolled in traditional Medicare.

Tens of millions of denials are issued each year for both authorization and reimbursements, and audits of the private insurers show evidence of “widespread and persistent problems related to inappropriate denials of services and payment,” the investigators found.

The report echoes similar findings by the office in 2018 showing that private plans were reversing about three-quarters of their denials on appeal. Hospitals and doctors have long complained about the insurance company tactics, and Congress is considering legislation aimed at addressing some of these concerns.

In its review of 430 denials in June 2019, the inspector general’s office said that it had found repeated examples of care denials for medical services that coding experts and doctors reviewing the cases determined were medically necessary and should be covered.

Based on its finding that about 13% of the requests denied should have been covered under Medicare, the investigators estimated as many as 85,000 beneficiary requests for prior authorization of medical care were potentially improperly denied in 2019.

Advantage plans also refused to pay legitimate claims, according to the report. About 18% of payments were denied despite meeting Medicare coverage rules, an estimated 1.5 million payments for all of 2019. In some cases, plans ignored prior authorizations or other documentation necessary to support the payment.

These denials may delay or even prevent a Medicare Advantage beneficiary from getting needed care, said Rosemary Bartholomew, who led the team that worked on the report. Only a tiny fraction of patients or providers try to appeal these decisions, she said.

“We’re also concerned that beneficiaries may not be aware of the greater barriers,” she said.

Medicare officials said in a statement that they are reviewing the findings to determine the appropriate next steps, and that plans found to have repeated violations will be subject to increasing penalties.

The agency “is committed to ensuring that people with Medicare Advantage have timely access to medically necessary care,” officials said.