Survey: 13% Of Medicare Advantage Claims, Prior Authorization Requests Denied

Survey shows 13% of Medicare Advantage enrollees had a claim or pre-authorization  request denied | Healthcare Finance NewsSource: Fierce Healthcare, by Robert King

A recent survey of Medicare Advantage enrollees found 13% had a claim or pre-authorization request denied as the program has gotten scrutiny over its prior authorization practices.

 

The survey, released Monday by the online insurance marketplace eHealth, also found that 67% of respondents chose MA over Medigap due to concerns over its affordability. The MA market has become an increasingly lucrative one for insurers, as projections expect enrollment to surpass traditional Medicare in the coming years.

“As demonstrated in this report, we found that a striking majority of Medicare Advantage enrollees are satisfied with their plans,” the survey said.

EHealth’s survey of more than 2,800 MA enrollees last month showed that a large majority (77%) did not have their claims or prior authorization requests denied, while 10% did not know and 13% reported they did have rejections.

Of the 13% who were denied coverage, 3% said they could not get a specific drug and 2% were for coverage visits.

“Those who experienced a self-reported denial of coverage include many who were declined for things like dental and vision care, which aren’t typically covered by Medicare,” the survey report said.

In addition, 43% of respondents who did have a claim or prior authorization request denied say their plan told them the claim was excluded from coverage. Another 15% said coverage was denied because the service wasn’t medically necessary.

But 15% of respondents who had a claim or request denied said that the insurer eventually paid it later.

The findings come amid increased scrutiny of MA insurers’ prior authorization practices. A report from the Department of Health and Human Services’ Office of Inspector General that analyzed 250 prior authorization denials and 250 payment denials from MA plans found the denials were sometimes for services that met Medicare coverage requirements.

For instance, 13% of prior authorization denials and 18% of payment declines were for services Medicare should cover.

 

The report comes as some lawmakers have criticized the MA program for driving up Medicare costs due to tactics to game risk adjustment scores and gain higher bonus payments.

EHealth’s report, however, showed that MA remains a very popular program with seniors. It found that 88% of respondents were satisfied with their coverage, and 63% were very satisfied.

One of the key benefits for the program is lower costs compared with Medigap plans as 67% of seniors said they chose MA because Medigap, which pays for supplement benefits not covered by traditional Medicare, was too expensive. Another 25% signed up with MA because Medigap did not offer drug coverage.

Patients Denied Mental Health Care in Non-Medicaid Expansion States

Nearly 570,000 people diagnosed with a serious mental health condition were denied affordable mental health treatments because several states have refused to participate in the new Medicaid Expansion Program, according to a study from the American Mental Health Counselors Association (AMHCA). The federal government would have paid 100% of the treatment costs for these patients. Also, 458,000 fewer people would have avoided a depressive disorder by securing health insurance through the Medicaid Expansion Program.

Many of the eligible people in the 24 non-Medicaid Expansion states had severe mental health conditions and did not have any health insurance coverage through public or private health plans. But they were denied the opportunity to get affordable coverage and treatments in those states due to ideological differences with the Obama Administration. The 26 states (and DC) that did participate in the expansion in 2014 helped 351,000 people with mental illness get affordable, needed services, and another 348,000 people did not develop a depressive disorder due to securing health insurance coverage. “If several states continue to opt out of the new Medicaid Expansion Program, thousands of state residents with a mental illness will see their hopes of a healthier and better life denied since they cannot get affordable health insurance and needed treatments due to political ideology. That is a very high price that seriously ill and vulnerable people have to pay for political differences,” said Dr. Steve Giunta, President of AMHCA. For more information, visit amhca.org.

Millions Are Denied Mental Health Treatment

Not only can mental illness can lead to death, but it is also the leading cause of disability. Millions of Americans face discrimination when they need help the most, according to the National Association of Psychiatric Health Systems (NAPHS). NAPHS president and CEO Mark Covall detailed the challenges in a letter submitted for a House of Representatives’ Energy and Commerce Oversight Committee hearing. According to Covall, a little-known provision in the law — Medicaid Institution for Mental Diseases (IMD) exclusion — prevents adult Medicaid enrollees (ages 21 to 64) from getting short-term, acute care in psychiatric hospitals. The exclusion penalizes the disabled and the poor. He stressed that people are not getting the psychiatric hospital treatment they need, putting families and communities at risk.  NAPHS is calling on Congress to modify the IMD exclusion. For more information, visit www.naphs.org.

Autistic Kids Being Denied Critical Care

A coalition of children’s health and autism support organizations says that hundreds of California’s children are suffering from disruptions in critical health care services as the state transitions from the Healthy Families Program to Medi-Cal. In particular, children in Healthy Families who had been receiving standard therapy for Autism Spectrum Disorders (ASD) are being denied these services in Medi-Cal, often with less than a week’s notice.

Governor Brown’s Administration has continually promised that no children would lose access to services during the multi-tiered transition of over 900,000 children from Healthy Families to Medi-Cal. California Health and Human Services Agency Secretary Diana Dooley was quoted as saying that officials would not shift children from Healthy Families to Medi-Cal unless they were sure the children would receive adequate health care: “We will delay the transition’ for certain children if they are unlikely to receive adequate care under Medi-Cal.” She said, “At this point, everything is on track.”

Now, after the transition of over 600,000 children to Medi-Cal, children’s health advocates say it is clear that everything is not on track. “These problems represent a shameful failure to provide for children who the state has known for at least six months were at risk of losing services,” said Ted Lempert, president of Children Now.

Advocates worry interruptions in autism services may foretell broader challenges. “We know that only a small percentage of affected families ever file a complaint, and since the state’s monitoring of the Healthy Families transition has been woefully inadequate, other continuity of care issues may take a while to surface,” added Karen Fessel, executive director and founder of the Autism Health Insurance Project.

Last Updated 06/29/2022

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