Insurers scrutinized for Medicare plans


Medicare health plans are in the spotlight once again, but not in a good way. Federal officials aren't pleased with the plans, citing dozens of federal audit reports that indicate the same kind of deficiencies year after year, reports the The New York Times.

There are nearly 54 million individuals enrolled in Medicare plans, with 16 million of that total enrolled in Medicare Advantage plans.

The Centers for Medicare & Medicaid Services found that in 61 percent of the audits, insurers "inappropriately rejected claims" for prescription drugs, notes The Times. The audits also found that Medicare plans repeatedly missed deadlines for making decisions regarding the coverage of certain medical care.

Capital BlueCross in Pennsylvania, Aetna, Wellcare and Tufts Health Plan have been cited for violating Medicare requirements, according to the article.

Federal officials told Capital BlueCross it could no longer enroll Medicare beneficiaries because the insurer's conduct poses a serious threat for members. "Violations resulted in enrollees experiencing delays or denials in receiving prescription drugs," Gerard J. Mulcahy, the Medicare official in charge of oversight and enforcement, told The Times.

For Aetna, claims state that the insurers failed to provide its members with certain benefits, notes Mulcahy. Yet a spokeswoman for Aetna said this was due to administrative problems and does not reflect the insurer's quality of care.

And last year, the Minnesota state attorney general sought to investigate Humana for repeatedly denying legitimate claims and overcharging members.

These findings aren't new. This past summer, CMS looked into Medicare Advantage and Medicare Part D plans, and found that the most frequent violations involved unapproved quantity limits, unapproved utilization management and improper use of prior authorizations or exceptions, among others, FierceHealthPayer previously reported.

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