Medicare Advantage Plans Often Deny Coverage for Eligible, Necessary Care: Report

THURSDAY, April 28, 2022 (HealthDay News) -- Coverage for eligible, necessary care is denied each year to tens of thousands of seniors with private Medicare Advantage plans, U.S. federal investigators say.

In a report released Thursday, the team from the inspector general's office of the U.S. Department of Health and Human Services said Medicare needs to improve oversight of these plans and strengthen enforcement against those private insurance companies with a pattern of improper denials of coverage.

About 28 million older people have Medicare Advantage plans, which offer privatized versions of Medicare that are often cheaper and provide a greater range of benefits than the traditional government program.

But the HHS findings challenge claims by the industry's main trade group that Medicare Advantage "delivers better services, better access to care and better value." Instead, the investigators said they found "widespread and persistent problems related to inappropriate denials of services and payment."

Their review of 430 denials by Medicare Advantage plans in June 2019 revealed that 13 percent of cases where care was denied for medical services were actually medically necessary and should have been covered. Based on that rate, the investigators estimated as many as 85,000 requests for prior authorization of medical care were potentially improperly denied in 2019. The report also said that Advantage plans refused to pay about 18 percent of legitimate claims, about 1.5 million payments, in 2019. In some cases, plans ignored prior authorizations or other documentation to support the payment.

A 2018 report by the HHS inspector general's office revealed that private plans reversed about three-quarters of their denials on appeal.

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