In the News

Medicare Advantage Plans Often Deny Needed Care, Federal Report Finds

New York Times

Investigators urged increased oversight of the program, saying that insurers deny tens of thousands of authorization requests annually.

Every year, tens of thousands of people enrolled in private Medicare Advantage plans are denied necessary care that should be covered under the program, federal investigators concluded in a report published on Thursday.

The investigators urged Medicare officials to strengthen oversight of these private insurance plans, which provide benefits to 28 million older Americans, and called for increased enforcement against plans with a pattern of inappropriate denials.

Advantage plans have become an increasingly popular option among older Americans, offering privatized versions of Medicare that are frequently less expensive and provide a wider array of benefits than the traditional government-run program offers.

Enrollment in Advantage plans has more than doubled over the last decade, and half of Medicare beneficiaries are expected to choose a private insurer over the traditional government program in the next few years.

The industry’s main trade group claims people choose Medicare Advantage because “it delivers better services, better access to care and better value.” But federal investigators say there is troubling evidence that plans are delaying or even preventing Medicare beneficiaries from getting medically necessary care.

The new report, from the inspector general’s office of the Health and Human Services Department, looked into whether some of the services that were rejected would probably have been approved if the beneficiaries had been enrolled in traditional Medicare.

Tens of millions of denials are issued each year for both authorization and reimbursements, and audits of the private insurers show evidence of “widespread and persistent problems related to inappropriate denials of services and payment,” the investigators found.

The report echoes similar findings by the office in 2018 showing that private plans were reversing about three-quarters of their denials on appeal. Hospitals and doctors have long complained about the insurance company tactics, and Congress is considering legislation aimed at addressing some of these concerns.

In its review of 430 denials in June 2019, the inspector general’s office said that it had found repeated examples of care denials for medical services that coding experts and doctors reviewing the cases determined were medically necessary and should be covered.

Based on its finding that about 13 percent of the requests denied should have been covered under Medicare, the investigators estimated as many as 85,000 beneficiary requests for prior authorization of medical care were potentially improperly denied in 2019.

Advantage plans also refused to pay legitimate claims, according to the report. About 18 percent of payments were denied despite meeting Medicare coverage rules, an estimated 1.5 million payments for all of 2019. In some cases, plans ignored prior authorizations or other documentation necessary to support the payment.

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President's Message

Posted: May 2, 2022

For the first time in a while, I found myself traveling just to visit an old friend this past weekend. He has been going through some medical challenges lately, and we haven’t seen each other since sometime in 2019. We think. Maybe longer. We both have jobs and families, and all of the trappings that come along with those. But we agreed to find a weekend, clear the calendar, and just catch up.

The point is, whatever is going on in the world, we have to continue to do the things and see the people that are important to us. We have (mostly) made it through the pandemic, and we need to figure out what life after that looks like—for ourselves, our families, our friends, and our profession.

How will telehealth and digital health impact us? What will the 2023 Final Rule look like? What about OASIS-E? These are some of the important questions that we are looking at. While these are important to our profession and to APTA Home Health, we want you, our members, to ask yourself your own important questions, whatever they may be. And sometimes, you realize the answer is to just do that thing, whatever it is.



 Phil Goldsmith
 APTA Home Health  


Call for Candidates: APTA Home Health OASIS Training Program

APTA Home Health is searching for a Program Director to lead its new OASIS Training Program. This is a contractual (1099) position with a quarterly stipend. Terms are a one-year contract with renewal provisions. The Program Director will report to the APTA Home Health Executive Committee, and interact frequently with Academy staff.

Goals of the program:

  • Elevate OASIS proficiency and accuracy for APTA Home Health members and others who complete the certification process
  • Allow physical therapists to practice at top of license and take on key roles within home health agencies

The Program Director will be expected to:

  • Recruit program faculty as needed
  • Develop and periodically update the program curriculum
  • Participate in budgeting and marketing initiatives with Academy staff and leadership
  • Facilitate production of course materials to the Academy’s existing Learning Management System
  • Establish standards for both initial certification and renewal of certification
  • Have the full curriculum available for public use no later than October 1, 2022, including all required elements for certification.

Interested candidates should e-mail a CV to [email protected] no later than May 15, 2022. Candidates should expect to be available for 1-2 weekday evenings between May 15, 2022, and June 5, 2022 for virtual interviews. The successful candidate will be notified by June 10, 2022, and can expect to start immediately thereafter.


Home Health Toolbox II: Tests & Measures For Use in the Home

Published in February 2022, the Home Health Toolbox II, for use by physical therapy practitioners and researchers, is an impressive and comprehensive aggregation of assessments across multiple domains, ranging widely from physical capacity to cognitive functioning to social factors impacting health and functioning. A selection of these assessments can give a full picture of a patient’s status in the home setting and should play an important role in characterizing a patient’s problems and challenges, developing a treatment plan and following progress over time.

The value of this Toolbox is that its developers have carefully screened for instruments that will work in the home setting and describe their strengths, weaknesses, technical requirements and interpretation.

APTA Home Health Member Price:  
- Digital: FREE
- Print Copy: $17.99 

Non-Member Price: 
- Digital Copy: $25.00
- Print Copy: $29.99 

To purchase your copy, click here


Highlights From APTA Combined Sections Meeting 2022

With the apt theme "Better Together. Together Again," APTA CSM 2022 brought the physical therapy community to San Antonio.

Much about the meeting was familiar: ample educational sessions hosted by APTA's sections and academies, networking opportunities such as breakfasts and receptions, an exhibit hall for viewing and trying out products and services, and the inspiring feeling of community that many attendees said was particularly meaningful this year.

But having learned a few things in the past couple of years, APTA also switched up some meeting elements, such as bringing the esteemed Mary McMillan Lecture and the annual Celebration of Diversity to APTA CSM, and adding an on-demand element that made over 100 recorded sessions available online following the meeting.

Click here for highlights! 

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