Federal Report Finds Inappropriate Denials From Medicare Advantage Plans

Private Medicare Advantage plans have grown considerably over the years, with enrollment more than doubling in the past 10 years. Currently, they provide benefits to some 28 million older Americans. However, as detailed in an April 28 New York Times article, a recent report from federal investigators found that these plans deny coverage of needed care for tens of thousands of Americans every year.

After reviewing 430 denials in June 2019, the inspector general’s office of the Department of Health and Human Services “found repeated examples of care denials for medical services that coding experts and doctors reviewing the cases determined were medically necessary and should be covered.” The investigators estimated that “85,000 beneficiary requests for prior authorization of medical care were potentially denied in 2019.” The report also found that Advantage plans also repeatedly refused to pay legitimate claims.

Hospitals and doctors have long complained about insurance company tactics, and Congress is considering legislation aimed at addressing some of these concerns. Meanwhile, the reports’ investigators urge Medicare to strengthen oversight of the plans and take action against plans with repeated inappropriate denials.

To read the report, see here: https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf