The report details how Medicare Advantage denial rates for post-acute care are significantly higher than for other types of care and also criticizes the payers’ use of artificial intelligence (AI) and predictive technologies to make prior authorization decisions – inferring the technology substitutes medical necessity judgments with financial calculations and leads to unnecessary denials of care.
The Senate Homeland Security and Governmental Affairs Committee’s majority staff report on Medicare Advantage highlights three key takeaways regarding overpayments and manipulative practices:
Medicare Advantage plans are significantly overpaid: The report concludes that Medicare Advantage plans are overpaid by billions of dollars annually due to inflated risk scores. These inflated scores are driven by practices like “upcoding” – exaggerating the severity of patients’ conditions to increase payments – and submitting diagnoses that lack sufficient supporting documentation. This overpayment burdens taxpayers and diverts funds from traditional Medicare.
MA Organizations engage in practices that deny or delay care: The report details how some Medicare Advantage Organizations (MAOs) employ practices that obstruct beneficiary access to medically necessary care. These tactics include inappropriately denying prior authorization requests, implementing overly restrictive utilization management practices, and creating cumbersome or opaque appeals processes. This ultimately harms beneficiaries who are denied needed services or face delays in receiving them.
CMS oversight is insufficient: While CMS has implemented some oversight mechanisms, the report finds them inadequate to address the widespread problems of overpayment and improper denials of care. The report argues that CMS needs to strengthen its oversight activities, including audits, enforcement actions, and data validation, to ensure MAOs are accurately reporting diagnoses and providing beneficiaries with timely access to medically necessary services.
Majority Staff Report & Senator Richard Blumenthal. (2024). Refusal of Recovery: How Medicare Advantage Insurers Have Denied Patients Access to Post-Acute Care. https://www.hsgac.senate.gov/wp-content/uploads/2024.10.17-PSI-Majority-Staff-Report-on-Medicare-Advantage.pdf
O’Connor, J. (2024, October 25). Senate report hits top 3 Medicare Advantage insurers over ‘refusal’ of skilled nursing, other coverage. McKnight’s Long-Term Care News. https://www.mcknights.com/news/senate-report-hits-top-3-medicare-advantage-insurers-over-refusal-of-of-skilled-nursing-other-coverage/
Siddiqi, Z. (2024, October 18). U.S. Senate Subcommittee Raises Alarm Over Medicare Advantage’s Denial of Post-Acute Care. Skilled Nursing News. https://skillednursingnews.com/2024/10/u-s-senate-subcommittee-cites-serious-concerns-on-medicare-advantages-denial-of-post-acute-care/
O’Connor, J. (2024, October 20). Who’s putting profits before patients now? McKnight’s Long-Term Care News. https://www.mcknights.com/daily-editors-notes/whos-putting-profits-before-patients-now/
Vogel, S. (2024, October 21). Senate report slams Medicare Advantage insurers for using predictive technology to deny claims. Healthcare Dive. https://www.healthcaredive.com/news/medicare-advantage-AI-denials-cvs-humana-unitedhealthcare-senate-report/730383/
AHCA reacts to U.S. Senate report finding dramatic increases in Medicare advantage insurers’ denial of access to care. (n.d.). https://www.ahcancal.org/News-and-Communications/Press-Releases/Pages/AHCA-Reacts-to-Senate-Report-Finding-Dramatic-Increases-Medicare-Advantage-Insurers-Denial-Access-Care.aspx
Improve Medicare Advantage reimbursements with payer contract management that puts payer rules in the hands of clinicians & billers.
