Medicare Advantage plans at times deny seniors access to medical care, federal watchdog finds

The report from the inspector general’s office of the Department of Health and Human Services is the latest red flag related to inappropriate denials by Medicare Advantage plans, which are run by private health care insurers. Annual federal audits have highlighted “widespread and persistent problems related to inappropriate denials of services and payment,” the office said.

Of the more than 64 million Americans covered by Medicare, more than 29 million are now enrolled in Medicare Advantage plans. The policies often have lower premiums and provide more services than traditional Medicare. But they may also have more limited networks of doctors and require prior approval or referrals for certain services.

“We would caution against using this report to draw any broad conclusions about overall MA performance,” said spokeswoman Kristine Grow, noting beneficiaries’ high satisfaction rates with their plans.

Also, AHIP said the report points out that Medicare Advantage insurers approve the vast majority of requests for services and payments. (The inspector general’s office also said that insurers issue millions of denials each year.)

Another industry group, Blue Cross Blue Shield Association, did not return a request for comment.

Inspector general report

The plans turned down some prior authorization requests from medical providers that likely would have been covered by traditional Medicare, according to the inspector general’s office. Among the denied requests, some 13% met Medicare coverage rules.

The office identified two common reasons behind the denials. In some instances, insurers used clinical criteria not contained in Medicare coverage rules — such as requiring an X-ray before allowing more advanced imaging, like an MRI. And the insurers ruled in some cases that documentation was not sufficient for approval, even though the inspector general’s physician reviewers found that existing medical records were enough to support the necessity of the services.

Also, Medicare Advantage plans denied payment requests, mostly because of human mistakes during manual claims reviews or because of system processing errors. Some 18% of payment requests that were denied met Medicare coverage rules and Medicare Advantage billing rules.

Some of the denied prior authorization and payment requests that met coverage and billing rules were later reversed, often because the beneficiary or provider appealed.

Recommendations for improvement

The inspector general’s office recommends that the Centers for Medicare and Medicaid Services, which oversees Medicare Advantage, issue new guidance on the appropriate use of insurers’ clinical criteria in medical necessity reviews and update its audit protocols to address the issues identified in the report. It also suggests CMS direct Medicare Advantage plans to take additional steps to reduce manual review and system errors.

CMS said it agrees with all these recommendations and is determining the next steps to take.

Medicare Advantage plans may institute additional requirements to better define the need for a medical service, but they cannot be more restrictive than traditional Medicare’s national and local coverage policies, the agency said. It conducts audits of plans’ compliance and targets areas of concern, such as services with high rates of denial. Plans found to have repeated violations are subject to penalties, sanctions and contract termination.

In its response to the report, CMS noted that the average number of issues cited per audit declined about 70% between 2012 and 2019 — a statistic that AHIP also pointed out in its comment.

This story has been updated with additional information.