Medicare Advantage plan problems include denied care and

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Congress should crack down on Medicare Advantage health plans for seniors that sometimes deny patients vital medical care while overcharging the government billions of dollars every year, government watchdogs told a House panel the last week of June.

Witnesses sharply criticized the fast-growing health plans at a hearing held by the Energy and Commerce subcommittee on oversight and investigations. They cited a slew of critical audits and other reports that described plans denying access to health care, particularly those with high rates of patients who were disenrolled in their last year of life while likely in poor health and in need of more services.

They also called for the Centers for Medicare & Medicaid Services, which runs the $350 billion-a-year program, to revive a foundering audit initiative that is more than a decade behind in recouping billions in suspected overpayments to the health plans, which are run mostly by private insurance companies.

Both Republican and Democratic subcommittee members stressed a need for improvements to the program while staunchly supporting it. Still, the detail and degree of criticism were unusual.

Seniors should not be “required to jump through numerous hoops” to gain access to health care, said Rep. Diana DeGette (D., Colo.), chair of the subcommittee.

Rep. Frank Pallone Jr. (D., N.J.), who chairs the influential Energy and Commerce Committee, said he was “deeply concerned” to hear that some patients are facing “unwarranted barriers” to getting care.

Under original Medicare, patients can see any doctor they want, though they may need to buy a supplemental policy to cover gaps in coverage.

Medicare Advantage plans accept a set fee from the government for covering a person’s health care. The plans may provide extra benefits, such as dental care, and cost patients less out-of-pocket, though they limit the choice of medical providers.

Those trade-offs aside, Medicare Advantage is clearly proving attractive to consumers. Enrollment more than doubled over the last decade, reaching nearly 27 million people in 2021. That’s nearly half of all people covered by Medicare, a trend many experts predict will accelerate as legions of baby boomers retire.

Medicare Advantage could lower costs and improve medical care but “is not meeting this potential” despite its wide acceptance among seniors, said James Mathews, who directs the Medicare Payment Advisory Commission, which advises Congress on Medicare policy.

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Related to denying treatment, Erin Bliss, a Department of Health and Human Services assistant inspector general, said one Medicare Advantage plan had refused a request for a CT scan that “was medically necessary to exclude a life-threatening diagnosis (aneurysm).”

The health plan required patients to have an X-ray first to prove a CT scan was needed.

Seniors “may not be aware that they may face greater barriers to accessing certain types of health care services in Medicare Advantage than in original Medicare,” Bliss said.

Seniors in their last year of life had dropped out of Medicare Advantage plans at twice the rate of other patients leaving the plans, said Leslie Gordon, of the Government Accountability Office, the watchdog arm of Congress.

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Notably absent from the hearing witness list was anyone from CMS, though CMS Administrator Chiquita Brooks-LaSure had been invited to testify. Rep. Cathy Rodgers (R., Wash.) said she was “disappointed” that CMS had punted, calling it a “missed opportunity.”

CMS did not respond to a request for comment.

AHIP, which represents the health insurance industry, released a statement that said Medicare Advantage plans “deliver better service, access to care, and value for nearly 30 million seniors and people with disabilities and for American taxpayers.”

Some of the most pointed criticism of Medicare Advantage plans and CMS’s oversight of them was related to home-based “health assessments,” which have been controversial for years. Because Medicare Advantage pays higher rates for sicker patients, health plans can profit from making patients look sicker on paper than they are.

Bliss said Medicare paid $2.6 billion in 2017 for diagnoses backed up only by the health assessments; she said 3.5 million members didn’t have any records of getting care for medical conditions diagnosed during those health assessment visits.

Although CMS chose not to appear at the hearing, officials knew years ago that some health plans were abusing the payment system to boost profits yet for years ran the program as what one CMS official called an “honor system.”

CMS aimed to change things starting in 2007, when it rolled out an audit plan ordering health plans to send CMS medical records that documented the health status of each patient and return payments when they couldn’t.

The results were disastrous, showing that 35 of 37 plans picked for audit had been overpaid, sometimes by thousands of dollars a patient. Common conditions that were overstated or unable to be verified ranged from diabetes with chronic complications to major depression.

Yet CMS still has not completed audits dating as far back as 2011, through which officials had expected to recoup more than $600 million in overpayments caused by unverified diagnoses.

In September 2019, KHN sued CMS under the Freedom of Information Act to compel the agency to release audits from 2011, 2012, and 2013 — audits the agency contends still aren’t finished. CMS is scheduled to release the audits later this year.

Kaiser Health News is a nonprofit national newsroom that covers health issues.

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