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.

AHIP Presses Congress, White House To Ramp Up Scrutiny Of Private Equity Provider Deals

AHIP presses Congress, White House to ramp up scrutiny of private equity  provider deals | Fierce Healthcare

Source: Fierce Healthcare, by Robert King

Health insurance trade group AHIP is calling for the White House and Congress to increase scrutiny of private equity control of providers, which the group worries could impact quality and costs.

 

The group earlier this week released letters sent to the White House and congressional leaders outlining parts of a new policy road map and priorities (PDF). Chief among them was more transparency surrounding private equity deals, which has grown in popularity across certain parts of the provider industry.

“While improving transparency of health care prices at the federal level has been a major focus, only the recent executive order related to nursing home care has applied to the activities of private equity entities of the health care marketplace, which have vastly different business models than other health care organizations,” the letter to President Joe Biden said.

AHIP wrote that there needs to be more transparency on private equity control of physician specialty groups and how the deals can impact quality and costs for patients.

The group noted in a white paper that back in 2018 private equity made up 45% of all health mergers and acquisitions. While initial deals applied to certain specialties like orthopedics and urology, AHIP said targets have expanded.

AHIP wants Congress to pass legislation that requires the public reporting of all private equity and hedge fund purchases of specialty groups and other providers such as emergency room physicians or ambulance providers. They also want the federal government to study any anticompetitive impact on the acquisition of providers by private equity firms.

 

Other key priorities in AHIP’s road map include:

  • * Advance use of site-neutral payments to ensure payments are the same no matter the site of care. The Centers for Medicare & Medicaid Services has cut Medicare payments in recent years to off-campus hospital clinics to bring the payments in line with those paid to physician clinics. But the effort led to a legal fight with the hospital industry.
  • * Support the expansion of home-based advance care via “value-based care and payment models,” the road map said.
  • * Remove barriers to telehealth access, which exploded in use since the onset of the pandemic; but, now, regulators are figuring out what to make permanent. AHIP wants the federal government to have network adequacy regulations to account for the availability of telehealth and to ban billing of “distant site facility fees for telehealth services.”

AHIP’s push to scrutinize private equity deals comes as the federal government has delivered more scrutiny of hospital merger deals. The Federal Trade Commission also launched a probe into physician practice acquisitions back in January 2021 to examine their impact on market competition.

Last Updated 06/29/2022

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