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WASHINGTON – Medicare Advantage plans, the popular alternative of private insurance to the traditional Medicare program, have unduly denied many claims for medical expenses to patients and doctors, federal investigators said in a new report. .
Private plans, which now cover more than 20 million people – more than a third of all Medicare beneficiaries – are incentivized to deny claims "in order to increase their profits," the report says.
The findings, released by the Inspector General of the Department of Health and Human Services, come as policies adopted in Washington create new incentives for older Americans to enroll in Medicare Advantage plans. Some experts predict that the share of Medicare patients in private plans could reach half within a few years.
"Because Medicare Advantage covers a large number of beneficiaries, even low service rates or inappropriately declined payments can create significant problems for many Medicare beneficiaries and their providers," says the report from the inspector. General, Daniel R. Levinson.
The annual open Medicare registration period starts on Monday and beneficiaries can join Medicare Advantage plans, change plans or return to the original Medicare. A large majority of beneficiaries will have access to 10 or more private plans.
But the Inspector General's report highlights the potential concerns of consumers. The investigators found "widespread and persistent problems with denial of care and payment in Medicare Advantage".
Relatively few people appeal against the refusal to claim, leaving insurers free to avoid payment. But those who appeal are often successful. About 75% of the calls resulted in the first level of examination.
More and more beneficiaries are choosing Medicare Advantage because, as their name suggests, diets offer potential benefits, including a doctor who can coordinate care. Private plans impose an annual limit on out-of-pocket expenses; Traditional health insurance is not there.
Federal officials predict that the number of enrollments in Medicare Advantage plans will reach 22.6 million, or 36% of beneficiaries, next year. The total number of people covered by Medicare is expected to reach 72 million by 2025, up from 60 million today.
Even as the Inspector General's report was released on Sept. 27, doctors, patients, and congressmen were worried about certain practices regarding Medicare Advantage plans.
"Patients may face barriers to timely access to care because of heavy and often unnecessary prior authorization requirements," a letter to the Trump administration said last week from a bipartisan group of more than 100 legislators .
Insurers defend the requirements. They "protect patients from unnecessary and inappropriate care" and help reduce costs, said Matt Eyles, President and CEO of America's Health Insurance Plans.
The growth of Medicare Advantage stems not only from consumer choice, but also from policies implemented in Washington. Several factors have helped create a favorable environment for Medicare Advantage plans, allowing them to reduce premiums or add benefits:
■ The Trump administration has approved a surge in private plan payments for 2019, saying it was "determined to release and strengthen the Medicare Advantage program."
■ In addition to the general corporate tax cuts passed last year, Congress granted additional tax relief to health insurers for 2019, by suspending the fees imposed on them by the Health Care Act. affordable.
■ Medicare Advantage plans may offer additional benefits, including transportation to the doctor's office, home delivery of hot meals, and home security devices such as wheelchair ramps and safety bars. support for bathrooms. Such benefits, which are generally not available in the traditional Medicare program, may be of interest to older Americans who want to combine social and medical services.
"One in two US seniors will benefit from Medicare Advantage by 2021, because of the industry-friendly rate and tax policies of the Trump administration," said Ana Gupte, a health care analyst. at Leerink Partners in New York.
John K. Gorman, a former Medicare executive, a consultant to many insurers, presented a similar forecast, predicting that 50 percent of beneficiaries would benefit from Medicare Advantage plans by 2025.
Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, said the agency was not trying to refer beneficiaries to Medicare Advantage rather than to original Medicare.
"We think it's very important that our beneficiaries make the choices that are best for them," she said, adding, "We do not run any Medicare beneficiaries anywhere."
Medicare plans receive fixed monthly payments from the government. In return, they are expected to provide the full range of services that patients need. If they keep patients healthy and reduce the need for hospitalization, they can often keep their costs below what they are paid by Medicare.
But refusing services can also reduce costs. In the last two years, Medicare has imposed fines of more than $ 10 million and taken other enforcement actions against private plans to overburden recipients, deny or delay prescription drug coverage and not give up following complaints from patients.
When a health plan refuses to authorize a service, the recipient can do without it. And when doctors are wrongly denied payment for services provided, says the report, they sometimes try to bill patients.
"Some beneficiaries and beneficiaries of Medicare Advantage were denied services and payments that should have been provided," concluded the Inspector General.
Insurers have been accused for years of similar tactics in other areas of business. "They save money when they do not provide care," said David A. Lipschutz, a lawyer at the Center for Medicare Advocacy's non-profit center.
Medicare evaluates the performance of private plans and uses a five-star rating system, with five being the best. Managers encourage recipients to consider ratings when selecting a plan.
But federal investigators have questioned the usefulness of ratings as a tool for recipients. Health plans cited for serious violations of the Medicare rules "may still receive a high number of stars" and premiums paid associated with higher ratings, reported the Inspector General.
As of 2019, the report states that "audit violations will no longer be reflected in the star rating."
New evaluations will add weight to the patients' experiences, as reported by the beneficiaries. Insurers say that 90% of Medicare Advantage members are satisfied with their plans.
Administration officials have accepted the Inspector General's recommendation to strengthen oversight of Medicare Advantage plans and "provide beneficiaries with clear and easily accessible information on serious breaches" of Medicare requirements.
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