Senate Subcommittee Hearing – Medicare Advantage Denials and Delays of Care

May 19, 2023

On May 17, 2023 the Senate Permanent Subcommittee on Investigations (PSI) conducted a hearing looking into denials and delays of care in the Medicare Advantage (MA) program.

Some key points discussed by Senators Blumenthal and Johnson included:

  • MA beneficiaries facing barriers to access of care and treatment
  • Delays/denials in medically necessary care
  • MA plans not offering, at a minimum, the same benefits and coverage criteria as original Medicare
  • MA plans are using proprietary tools (algorithms and Artificial Intelligence (AI)) to make patient care decisions
    • There is a need for transparency by MA plans on how they utilize these tools
    • The three big MA plans (United HealthCare, Humana, and CVS/Aetna) were sent a Senate bipartisan letter on May 17, 2023 asking for internal documents to be provided, which describe how prior authorization decisions were made, to include the utilization of AI tools
  • Lack of free-market competition in the MA space

Some interesting stats that were presented during the hearing:

  • As of 2023, there are 30 million Americans enrolled in MA plans, a little over half of the eligible Medicare beneficiary population
  • In 2023, the average Medicare beneficiary has the option to choose from 43 MA plans – available from 9 different insurers
  • The top three MA plans (UHC, Humana, CVS/Aetna) cover over 50% of all MA beneficiaries
  • In 1949, $0.68 of every dollar in healthcare was paid by the consumer and $0.32 was paid by a 3rd party payer, compared to $0.11 and $0.89 respectively in 2023
  • According to MedPac, MA plans received $2,300 more per person than what was needed to cover costs of services… this additional revenue was used to provide extra benefits to MA beneficiaries (e.g., dental, vision, hearing) and added to insurers’ profits
  • In 2021, over 35 million prior authorization requests were submitted to MA plans
    • 6% were denied, of which 11% were appealed
      • Of the 11% appealed, over 80% were overturned

The hearing was chaired by Senator Richard Blumenthal (D-CT) and included ranking member Ron Johnson (R-WI).  Witnesses who testified included Megan Tinker, Chief of Staff, Office of Inspector General (OIG); Jeannie Fuglesten Biniek, PhD, Assoc. Director, Program on Medicare Policy at KFF (previously Kaiser Family Foundation); Christine Huberty, Lead Benefit Specialist Supervising Attorney with Greater Wisconsin Agency of Aging Resources; Lisa Grabert, Visiting Research Professor, Marquette University College of Nursing; and Gloria Bent, widow of Gary Bent MA Enrollee.

Watch the video from the hearing and read the witnesses testimony here:

Things you can probably expect to see in the future:

  • Increased scrutiny and investigations/audits of MA plans
  • Increased scrutiny of MA plans’ Prior Authorization processes (keep in mind that on April 12, 2023 CMS issued a final rule that described new requirements for Prior Authorization in the MA program).  Since the MA market has grown significantly in the last few years, the OIG is asking the Senate for additional funding to be able to manage the increased workload they are seeing with Fraud, Waste, and Abuse (FWA).
  • Demand for increased transparency by MA plans
  • Submission of detailed prior authorization & denial data to CMS (possibly with Encounter Data)
  • More focus on long-term care/skilled nursing facilities
  • Continued discussion on removing barriers to accessing care and treatment for MA beneficiaries
  • Increased collaboration with clinicians/healthcare professionals in solving barriers to care

Whether as a provider or health plan, there are a couple of things that can be done proactively:

  • Consider overall operational strategy involving the MA program – denials and delays of care/treatment are current hot topics, but more governmental resources can be expected to be deployed to investigate/audit plans and providers due to the following:
    • the significant growth to the MA program
    • the federal dollars associated with care of MA beneficiaries, and
    • the increased potential of FWA
  • Conduct an un-biased, independent review of operations – identify and address red flag issues; look for low hanging fruit that can be quickly and efficiently addressed
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