There’s a lot of variation in how often Medicare Advantage plan denials were overturned. In 2016, seven Medicare Advantage contracts had almost all of their denials reversed on appeal -- more than 98 percent. Another 69 contracts had denial rates above 90 percent. The report doesn’t name specific companies or plans. Individual insurers can have more than one Medicare Advantage contract with the government.
Problems with denials of care aren’t isolated to a few plans, however. The Centers for Medicare and Medicaid Services, or CMS, audits different organizations each year, “but consistently find problems related to denials of care and payment,” Rawlins said.
The CMS audits are one of many factors that affect health plans’ star ratings, which are intended to help Medicare patients shop for plans based on quality. But starting in 2019, as the result of a change by CMS, the audits will no longer be a factor in the ratings, “which diminishes the usefulness of the star ratings system as a tool for beneficiaries,” the report said.
The inspector general recommended that CMS increase its oversight of Medicare Advantage plans and give patients better information about violations. The agency concurred with the findings.
A CMS spokesperson said in an email that the agency is committed to “strong oversight and enforcement of the Medicare Advantage program to ensure that plans are delivering care to Medicare beneficiaries” as required.
This article was provided by Bloomberg News.