House Lawmakers Call Out ‘Bad Actors’ Within Medicare Advantage

Home Health Care News | By Joyce Famakinwa
 
House lawmakers are pushing for more oversight of Medicare Advantage (MA) plans in light of concerns over higher spending, improper claim denials and access to treatment.
 
A number of lawmakers on the House Energy and Commerce Committee’s oversight subcommittee examined the issue during a hearing that centered around the MA program on Tuesday.
 
“I am deeply concerned with recent reports that seniors in private sector Medicare Advantage plans are facing unwarranted barriers to accessing timely, medically necessary care,” Energy and Commerce Chairman Frank Pallone, Jr. (D-N.J.) said during the hearing. “Several studies have raised concerns that insurance companies are denying beneficiaries’ access to treatment and imposing burdensome requirements that delay care. Improper claim denials and increased use of prior authorizations are preventing beneficiaries from receiving the care they need.”
 
Pallone noted that while many Medicare Advantage plans seemed to be acting responsibly, “bad actors” were endangering the health of seniors and increasing costs for taxpayers.
 
Though several officials from federal agencies testified, including the U.S. Department of Health and Human Services Office of the Inspector General (HHS-OIG), the Medicare Payment Advisory Commission (MedPAC) and the Government Accountability Office. The U.S. Centers for Medicare & Medicaid Services (CMS) was not represented at the hearing.
 
“It’s a shame CMS did not agree to testify at this hearing to speak to the work the agency is doing to improve this program,” Rep. Morgan Griffith (R-Va.), a ranking member of the subcommittee, said.
 
Additionally, no MA plans spoke at the hearing.
 
During the hearing, Erin Bliss, the assistant HHS inspector general, pointed to OIG findings that plans were using chart reviews or in-home health risk assessments to diagnose patients. Oftentimes, there would be no follow-up.
 
In total, these diagnoses resulted in an estimated $2.6 billion in risk-adjustment payments for 2017.
 
Bliss also expressed that plans sometimes delayed or denied beneficiaries’ access to medical care, despite the requested care being medically necessary and meeting Medicare coverage rules.
 
“In other words, these Medicare Advantage beneficiaries were denied access to needed services that likely would have been approved if the beneficiary had been enrolled in original Medicare,” she said. “These denials likely prevented or delayed needed care for beneficiaries.”

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