An increasing number of older Americans are being forced by states to enroll in Medicare Advantage plans, which critics charge is simply Medicare privatization under a different name. (Note: read this.)
Now, a federal watchdog reports, it’s not going well for the enrollees in these plans, according to AARP:
Private health insurance plans for Medicare beneficiaries wrongly denied tens of thousands of requests for tests and treatment each year, jeopardizing the health of many older Americans, according to the top federal watchdog overseeing the program.
“Denying requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care,” says a report by the U.S. Department of Health and Human Services’ Office of Inspector General in late April.
The inspector general called on the Centers for Medicare & Medicaid Services (CMS), which oversees Medicare, to more tightly regulate these plans to make sure they are following Medicare’s rules for what should be covered.
CMS agreed with the findings and said the agency is weighing its next steps. Enrollment in Medicare Advantage (MA) plans has increased significantly over the past decade, with 42 percent of Medicare beneficiaries (26.9 million) taking part as of 2021. Private insurers receive a flat monthly fee for every Medicare beneficiary they cover.
Investigators said this created “the potential incentive for insurers to deny access to services and payment in an attempt to increase profits.” Under original Medicare, the federal government pays providers directly for each service or treatment that Medicare covers.
Who could have ever guessed that if you paid a flat fee to gigantic Wall Street corporations, meant to cover all care per person, that those corporations would find ways to deny potentially life-saving care for older Americans just to make more profit?
It’s as if someone, somewhere along the line forgot that the point of Wall Street is not providing the best health care possible, but rather they exist to find ways to shovel more money at executives and shareholders.
According to the HHS inspector general, it discovered that health care procedure prior authorizations, often required under Advantage plans, are being wrongly denied:
Our case file reviews determined that MAOs sometimes delayed or denied Medicare Advantage beneficiaries’ access to services, even though the requests met Medicare coverage rules. MAOs also denied payments to providers for some services that met both Medicare coverage rules and MAO billing rules. Denied requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers. Although some of the denials that we reviewed were ultimately reversed by the MAOs, avoidable delays and extra steps create friction in the program and may create an administrative burden for beneficiaries, providers, and MAOs. Examples of health care services involved in denials that met Medicare coverage rules included advanced imaging services (e.g., MRIs) and post-acute facility stays (e.g., inpatient rehabilitation).
Introducing the Wall Street profit motive into health care has never worked for patients.
Never forget also that AARP has skin in this game as it partners with United Healthcare to provide its own Medicare Advantage plans. A partnership that brings AARP a great deal of money it does not fully disclose. And, the United Healthcare connection is not the only possibly shady self-dealing in which AARP engages. AARP makes more money from these “alliances” than it does from membership dues, according to KHN, including a partnership with a chain of private equity-funded medical clinics under investigation for possible billing fraud.