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Medicare Advantage Plans Hit Back at Report on Coverage Denials

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What You Need to Know

  • A report released last week highlighted Medicare Advantage plan preauthorization and coverage denials.
  • AHIP notes that investigators raised concerns about just 33 of 247 preauth requests.
  • For many of the denials, the main reason was lack of guidance from the government, AHIP says.

Medicare Advantage plans approve most requests for coverage for care, according to a group for health insurers.

When the plans do deny preauthorization request incorrectly, the main reason is often lack of clear advice from Medicare program managers, the group says.

America’s Health Insurance Plans — a Washington-based group for health insurers — defended the plans’ coverage decisions in a response to a report, released Thursday, by the U.S. Department of Health and Human Services’ Office of Inspector General.

The Medicare Advantage program lets health insurers provide plans that look, to the enrollees, like alternatives to the original Medicare Part A hospitalization and Part B physician and outpatient services coverage.

HHS OIG investigators said they analyzed a sample of about 250 care preauthorization denials issued during one week in June 2019, and that they believe that 13% of the denials were wrong.

AHIP said it believes that the HHS OIG report, and press coverage of the report, gave a misleading impression of Medicare Advantage plans’ performance.

“The OIG noted that the overwhelming majority (95%) of prior authorization requests in 2018 were approved,” AHIP said.

HHS OIG investigators objected to Just 33 of the 247 preauthorization denials analyzed, the group added.

“The main concern about many of those cases was not that they were improper, but rather than more guidance from the government was needed on criteria that plans can use to make coverage determinations,” AHIP said.

Physicians’ View

The American Medical Association — a Chicago-based group that represents physicians — said it agrees with the HHS OIG Report.

“An investigation by the inspector general’s office of the Health and Human Services Department into the inappropriate use of prior authorization by Medicare Advantage plans uncovered information that mirrors physician experiences,” the AMA said.

“Surveys of physicians have consistently found that excessive authorization controls required by health insurers are persistently responsible for serious harm when necessary medical care is delayed, denied, or disrupted,” the AMA added. “The American Medical Association agrees with the federal investigators’ recommendations for preventing inappropriate use of authorization controls to delay, deny and disrupt patient care.”

AHIP Defends Preauthorization Programs

AHIP argued that preauthorization program can keep patients from getting dangerous, unnecessarily expensive or unnecessary care.

Many physicians have estimated that 15% to 30% of medical care is unnecessary, and preauthorization programs can reduce use of unnecessary care, AHIP said.

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