You may have seen the headlines, but it always pays to read the between the lines; get the details.
Those plans (MA) are offered because they are very profitable for the companies. However, a new report from the Office of the Inspector General (IG) of the Department of Health and Human Services raises troubling questions about how some companies are trying to increase their profits.
According to the report, some companies have denied access to medically necessary care by denying prior authorization and payment requests that, in fact, met Medicare coverage rules. They have done that by:
using clinical criteria that are not contained in Medicare coverage rules;
requesting unnecessary documentation;
and making manual review errors and system errors.
They have also sometimes denied payments to providers for some services that met both Medicare coverage rules and the companies’ own billing rules.
Denying requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers.
Yes, it’s true, but what is not said is that this report is a sampling of 250 claims in each category. They found errors in 13% of the cases for care requests and 19% for physician denial.
Keep in mind these reviews by insurers are based on judgement. In addition, there are errors made – including by Medicare.
Likely a greater problem from a cost standpoint and to some extent patient care is the fact…
Traditional Medicare, historically, has rarely required prior authorization. Originally, the Social Security Act did not authorize any form of “prior authorization” for Medicare services, but the law has subsequently been changed to allow prior authorization for limited items of Durable Medical Equipment and physicians’ services. Despite this change, there are still very few services requiring Prior Authorization in traditional Medicare.* Enrollees in traditional Medicare Parts A and B can generally see specialists, visit hospitals, get care out of state, and so on, without having to ask Medicare’s permission.