‘It was stunning': Bipartisan anger aimed at Medicare Advantage care denials
Complaints from lawmakers over Medicare Advantage care denials are rising, which could spark CMS to increase its oversight of the program. | Alex Wong/Getty Images
A bipartisan group of lawmakers is increasingly concerned that insurance companies are preying on seniors.
by ROBERT KING
Enrollment in Medicare’s private-sector alternative is surging — and so are the complaints to Congress.
More than 30 million older Americans are enrolled in Medicare Advantage plans, wooed by lower premiums and more benefits than traditional Medicare offers.
But a bipartisan group of lawmakers is increasingly concerned that insurance companies are preying on seniors, and, in some cases, denying care that would otherwise be approved by traditional Medicare.
“It was stunning how many times senators on both sides of the aisle kept linking constituent problems with denying authorizations for care,” Sen. Ron Wyden (D-Ore.) said in an interview, referring to a bevy of complaints from colleagues during a recent Senate Finance Committee hearing.
Congress has already gone after insurers for their celebrity-filled ads and misleading directories. But its scrutiny of these care denials, which is expected to continue into next year, could have a far greater impact and reshape the rules for one of the most profitable parts of the insurance industry.
“CMS is very attuned to what is going on on the Hill,” Sean Creighton, managing director of policy for consulting firm Avalere Health, said of the Centers for Medicare and Medicaid Services. He added that next year will likely bring “more scrutiny by the Hill and CMS on this, and there will be more reporting requirements for the plans and actions the plans are required to take to lessen the burden on providers and patients.”
Legislation requiring insurers to more quickly approve requests for routine care passed unanimously in the House in 2022, but stalled in the Senate over cost concerns. The Improving Seniors’ Timely Access to Care Act, which mandates insurers quickly approve requests for routine care and respond within 24 hours to any urgent request, was reintroduced this year in the House and passed out of the House Ways and Means Committee this summer as part of a larger health care package.
Still, lawmakers are peppering the Biden administration with demands for reforming the commonly used tool called prior authorization, the process in which health insurers require patients to get insurer approval ahead of time for certain treatments or medications.
It “has turned into a process of basically just stopping people from getting care,” said Rep. Pramila Jayapal (D-Wash.), leader of the House Progressive Caucus.
Jayapal was one of more than three dozen House Democrats who told CMS this month of “a concerning rise in prior authorizations,” accused health insurers of prioritizing “profits over people” and asked for “a robust method of enforcement to rein in this behavior.”
Unlike traditional Medicare, Medicare Advantage plans can employ prior authorization and restrict beneficiaries to certain doctors within their network. Those are among the incentives private insurers have to participate in the program and enrollment has doubled during the last decade.
But Sen. James Lankford (R-Okla.) said some hospitals in his state won’t take Medicare Advantage plans any more. “We can’t do it because we can’t afford the constant chasing from all the denials,” he said.
AHIP, the trade group representing insurers, told POLITICO that prior authorization was among the tools that can curb wasteful spending.
“These tools are important when coordinating care, reducing unnecessary and low-value care, and promoting affordability for patients and consumers,” said spokesperson David Allen in a statement.
CMS has a track record of responding to liberal concerns, which could translate into big changes for Medicare Advantage in the coming years. Earlier this month, it proposed a rule to improve the standards for behavioral health networks following complaints from Congress about woefully inaccurate mental health provider directories, which some lawmakers said amounted to fraud.