Let's address the dark side of Medicare Advantage plans


Medicare Advantage plans are frequently lauded for providing high-quality insurance coverage. And they're widely popular among Medicare-eligible consumers. But there's a dark side to these plans as well.

In fact, dozens of federal audit reports indicate that Medicare Advantage plans make the same kind of deficiencies year after year, especially when it comes to inappropriately rejecting claims. The Centers for Medicare & Medicaid Services found that in 61 percent of the audits, insurers turned down claims for prescription drugs when they shouldn't have.

This is not something to take lightly. Many seniors take prescription medications, and many of those drugs are vital to their health and medical conditions. To potentially block their access to those drugs could prove extremely detrimental.

But what might be most alarming is that these deficiency findings aren't new. CMS reviewed Medicare Advantage and Medicare Part D plans over the summer and found that the most frequent violations involved unapproved quantity limits, unapproved utilization management and improper use of prior authorizations or exceptions, among others.

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

It's these sorts of discoveries that led a senior official with the Department of Health and Human Services to urge CMS to implement tighter audit standards.

Considering all the money that is funneled into Medicare Advantage plans--and the discussions about whether to cut back those funds--I would like to think that federal officials are heavily scrutinizing the insurers in the program. When millions of dollars are at stake, HHS must constantly analyze Medicare Advantage insurers' performance.

Medicare Advantage is a great money-making business for insurers--particularly if they continue inappropriately denying prescription claims and improperly requiring authorizations. I'm all for insurers helping the federal government administer the Medicare Advantage program, but not without checks and balances.

What's more, these audits should be made more available to consumers shopping for Medicare Advantage plans. Highlighting the audits could even do some of the work for HHS. I don't know anyone who would select a plan that's likely to reject their needed meds, so consumers would be making an informed decision about their health insurance coverage. And the insurers would change their practices to guarantee they don't lose members, thereby relieving HHS from having to oversee and force insurers into following guidelines.

That's a win-win situation that could remove any dark side from an otherwise successful program. - Dina (@HealthPayer)

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