Medicare Advantage plans denied nearly 1 in 5 claims that should have been paid, HHS finds

A new government watchdog report has found that private Medicare plans routinely rejected claims that should have been paid and denied services that reviewers found to be medically necessary.

The report, done by U.S. Department of Health and Human Services inspector general’s office investigators, found private Medicare plans denied 18% of claims allowed under Medicare coverage rules. The denials often were a result of errors in processing claims.

The review also found private Medicare plans turned down 13% of authorizations for medical services that government-run Medicare would have allowed.

The inspector general reviewed hundreds of authorization and payment denials by 15 of the largest Medicare Advantage plans over one week in June 2019. Coding experts and physician reviewers examined the cases, and the agency estimated how often insurers denied requests that should have been covered.

The report cited two reasons private Medicare plans rejected authorizations that the watchdog’s agency’s physician reviewers found to be medically necessary. The private plans had coverage formulas beyond what Medicare required — such as first requiring an X-ray before allowing other scans such as an MRI. The plans also claimed the request lacked appropriate documents, though the investigators said beneficiaries’ medical records were enough to support these requests.

The inspector general said the agency that oversees Medicare should tighten oversight, issue new guidance for clinical reviews employed by private Medicare plans and order private plans to fix vulnerabilities that can lead to review errors.

These private Medicare plans cover more than 28 million older and disabled Americans and are an increasingly popular option, with total enrollment more than doubling over the past decade. By 2030, the Congressional Budget Office projects that more than half of Medicare beneficiaries will be in a private Medicare plan.

Medicare Advantage plans tout perks such as limited out-of-pocket costs, vision and dental benefits not offered by traditional Medicare and even gym memberships.

But the plans employ private insurance industry tactics to reduce costs. These plans restrict networks of doctors and other medical providers people can use, mandate authorization for some services and require referrals for specialists.

Rosemary Bartholomew, a Medicare Advantage expert who led the team that wrote the report, said beneficiaries might be denied care they need or might pay for services their plans should cover.

Another worry is that such routine claims and care denials could prompt doctors and patients to appeal the initial decisions, leading to extra work and more of an administrative burden.

Bartholomew said oversight investigators’ concerns for traditional Medicare are on the overall services performed because Medicare pays doctors and hospitals for each test or procedure.

Because private Medicare plans generally are paid a fixed amount per patient, Bartholomew said, “There can be an incentive to kind of stint on care a little bit in order to increase profits.”

Jack Hoadley, a Georgetown University McCourt School of Public Policy research professor emeritus, said the report suggests that some private Medicare plans are aggressive at denying or delaying care.

“This is evidence that there needs to be increased scrutiny, more auditing and more oversight,” Hoadley said.

Read more at USA Today.