When Medicare Advantage was first introduced as a health-care option, it promised many things, the most important of which was more care options at a lower cost.
According to a recent government Inspector General's report, that initial promise may not be kept. Some Medicare Advantage Organization (MAO) recipients have even been denied care through this private-public health maintenance organization-like program, which runs counter to Medicare's mission of providing care to all who qualify.
"Although MAOs approve the vast majority of requests for services and payment," according to the report, "they issue millions of denials each year, and annual audits of MAOs have highlighted widespread and persistent problems related to inappropriate service and payment denials."
"Our case file reviews revealed that MAOs sometimes delayed or denied Medicare Advantage beneficiaries' access to services, even when the requests met Medicare coverage rules," according to the report summary.
"MAOs also denied provider payments for some services that met both Medicare coverage and MAO billing rules." Requests that meet Medicare coverage rules that are denied may prevent or delay beneficiaries from receiving medically necessary care and may place a burden on providers."
People who sign up for Medicare Advantage, according to one health care lawyer, are giving up their right to have a doctor determine what is medically necessary, rather than having the insurer decide.
The investigators urged Medicare officials to increase oversight of Advantage plans and provide customers with "clear, easily accessible information about serious violations."
In a statement, Medicare officials stated that they are reviewing the findings to determine the appropriate next steps, and that plans found to have repeated violations will face increasing penalties.
Officials stated that the agency "is committed to ensuring that people with Medicare Advantage have timely access to medically necessary care."
"We also discovered that some of the denied prior authorization and payment requests that met Medicare coverage and MAO billing rules were reversed by MAOs." Reversals occurred frequently when a beneficiary or provider appealed or disputed the denial, and in some cases, MAOs acknowledged their own errors."
