It’s becoming increasingly clear that the government needs to rein in Medicare Advantage. 

Thursday’s heavy-hitting report from the Office of Inspector General, which is part of the Department of Health and Human Services, provided the latest reminder of that. The OIG found that Medicare Advantage Organizations (MAOs) are denying or delaying Medicare-covered services to beneficiaries. It also asserted that the plans denied payments to providers for services that met Medicare coverage rules and MA billing rules.

While it noted that MAOs ultimately reversed some of the denials, it pointed out that “avoidable delays and extra steps create friction in the program and may create an administrative burden for beneficiaries, providers and MAOs.”

Some of the denials are cringeworthy. In one case cited by the OIG, an MAO denied a request to transfer a beneficiary from the hospital to a skilled nursing facility stating that home health services could meet that person’s medical needs. That person had pain and swelling from cellulitis and bedsores. The patient also couldn’t carry out activities of daily living and was no longer able to walk with the help of a rolling walker. The OIG determined that the person needed skilled care. The MAO reversed the denial on appeal.

In another, an MAO denied a request for an MRI for a 91-year-old with chronic low back pain and sciatica. Why? The person had not completed six weeks of provider-directed treatment within the preceding three months. A physician panel determined that the beneficiary needed the MRI and did not require six weeks of prior treatment.

The criticisms are not new, mind you. The OIG in 2018 found that Medicare Advantage Organizations overturned 75% of their own denials during 2014 to 2016.

But the environment for MA plans is different today. MA plans are growing exponentially, with MA plans expected to surpass 50% of Medicare lives by 2030, according to the Congressional Budget Office. And with the Centers for Medicare & Medicaid Services’ adoration — it is giving them an 8.5% increase next year — there seems to be no stopping them. But CMS should.

It’s obvious that insurance companies are reaping major profits from MA. Home, which is the cheapest setting for care, increasingly, is part of the corporate strategy. UnitedHealth Group’s recent purchase of LHC Group, one of the largest home health companies, demonstrates that. 

Don’t get me wrong. The movement toward the home — the place where people want to age — is a sign of progress. But there need to be adequate guardrails to ensure that insurance plans are not running off with the money and leaving the patients behind.  

Liza Berger is editor of McKnight’s Home Care. Email her at [email protected]

Related Articles