The long-awaited report from the investigation by the Senate Homeland Security Committee’s Investigative Subcommittee related to Medicare Advantage coverage denials has been released.
The report once again puts Medicare Advantage in the spotlight. While Medicare Advantage (MA) often boasts lower premiums than traditional Medicare, it has been criticized for higher rates of care denials, primarily due to network restrictions and prior authorization processes. Additionally, the program is oftentimes more expensive for the government than traditional Medicare, raising concerns about its impact on the long-term financial sustainability of Medicare.
MA coverage denials directly impact allergists who accept Medicare, and they harm allergy patients’ access to life changing care. The report provides background on how MA plans have increasingly relied on prior authorization for all types of services and how artificial intelligence (AI) has exacerbated the issue.
The report validates what most allergy practices already know: that the problem is getting worse. It highlights how coverage denials by the three major MA insurers – United Healthcare, Humana, and CVS Aetna – have increased since 2020. However, the report’s findings mostly focus on post-acute care.
What is particularly concerning is that MA plans now cover more than half of all Medicare beneficiaries, making these denials a widespread issue affecting the 32.8 million seniors enrolled in MA plans.
While it’s difficult to attribute the rise in coverage denials to a single cause, the report dedicates a section to the use of AI algorithms in evaluating prior authorization requests. It suggests a possible link between the increasing reliance on AI and the significant rise in care denials.
To begin addressing the identified problems, the report asked CMS to begin collecting prior authorization information broken down by area of care, to ensure that older Americans are not disproportionately being impacted by coverage denials. It also recommends targeted audits of insurance providers’ prior authorization data to reveal notable increases in adverse determination rates.
To combat the care denials, Senator Roger Marshall (R-KS) reintroduced the Improving Seniors’ Timely Access to Care Act of 2024 last June. The Act would codify a recently finalized CMS regulation that creates an electronic standard for prior authorization to expedite approvals, defines timelines for health plans to review these requests, and requires MA plans to report on their prior authorization practices, including approval and denial rates.
The College officially endorsed this bill when it was reintroduced.
If the themes that emerged from this report continue, Congress may eventually look to take another step to ensure that seniors with MA are not disproportionately denied access to care.
One striking insight from the report showed that United Healthcare doubled the rate at which it denies patient hospital stays between 2020 and 2022.
Humana’s denial rate for long-term acute care hospitals grew by 54% during the same period. Similarly, the number of post-acute care services for which CVS Aetna requested prior authorization increased by 57.5%.
The report indicates that care denials disproportionately affect hospitals compared to independent practices.
These findings suggest that major insurance companies may not be adequately covering post-acute care, as it is being denied at much higher rates than other forms of patient care. Since post-acute care includes long-term hospital stays, inpatient rehabilitation facilities, and skilled nursing homes, these care denials are disproportionately felt by older Americans enrolled in MA plans.
The College will continue to advocate for MA reforms and overburdensome prior authorization to help allergists focus on their patients instead of paperwork.
The College has tools to help simplify prior authorizations. You can create personalized, scientifically based prior authorization appeal letters for 14 different drug/disease combinations in under 10 minutes, get tips from our prior authorization experts and find resources to share with your patients and staff. Everything you need is in our Prior Authorization Toolkit!
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
