Medicare Advantage Plans Wrongly Denied Medical Care

Private Health Insurance Plans for Medicare Beneficiaries wrongly Denied tens of thousand of Requests for Tests and Treatment each year, Jeopardizing the Health of many Older Americans, according Top Federal Watchdogs overseeing the Program.

Denying requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care, says a Report by the U.S. Department of health and Human Services' (HHS) of Inspector General (IG) in late April.

The IG called on the Centers for Medicare & Medicaid Services (CMS), which oversees Medicare, to more tightly Regulate these Plans to make sure they are following Medicare's Rules for what should be Covered. CMS agreed with the Findings and said the Agency is weighing its next steps.

Enrollment in Medicare Advantage (MA) Plans has Increased significantly over the past Decade, with 42% of Medicare Beneficiaries, 26.9 million, taking part as of 2021. Private Insurers receive a Flat Monthly Fee for every Medicare Beneficiary they cover. Investigators said this created the potential incentive for insurers to deny access to services and payment in an attempt to increase profits.

Under original Medicare, the Federal Government pays Providers directly for each Service or Treatment that Medicare covers. The MA Plans can require Pre-Authorization for a Test or treatment.

Federal Investigators reviewed a week's worth of those Requests in 2019 and found that od those denied, 13% would have been allowed under original Medicare. Based on that sampling, Inspectors estimated 85,000 Requests would have been wronly Denied that year.

That would delay or prevent beneficiary access to medically necesdary care, lead beneficiaries to pay out of pocket for services that are covered by Medicare, or create an administrative burden for beneficiaries or their providers who choose to appeal the denial, theReport says.










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