Over the years, Medicare Advantage (MA) managed care plan violations have made national headlines for lack of transparency in reporting, access to care issues, and questionable financial practices. MA plan accountability is especially important as MA accounts for over 50% of the Medicare enrollment, and the federal government is anticipating an expenditure in excess of 7 trillion dollars in the next decade.
Despite legal, financial, and ethical ramifications, MA plans have largely failed to provide payment and coverage for the intended benefits offered to beneficiaries. MA plans are intended to cover all Medicare services plus additional benefits that may include pharmacy, dental, vision, hearing care, transportation, and fitness memberships, yet the Office of Inspector General (OIG) recently raised concerns about MA plan transparency and beneficiary access to care.
MA plans were cited for denials of service and payment, as identified:
• Inappropriate denials: OIG reports have found instances where MA plans denied medically necessary services or payments to providers, even when the Medicare coverage rules were met. This raises concerns about beneficiaries' access to care and potential financial gain for plans.
• Lack of transparency: The current system for tracking denied claims is inadequate, making it difficult to identify and address inappropriate denials effectively.
• Prior authorization burdens: OIG has found that some plans request unnecessary or duplicative documentation for prior authorization, creating delays in the provision of medically necessary care for beneficiaries.
MA plans were also cited for plan costs and benefit concerns, as further explained:
• High medical loss ratios (MLRs): Some plans have MLRs (percentage of premium spent on medical care) lower than industry standards, raising questions about whether beneficiaries are receiving adequate value for their premiums.
• Limited transparency on supplemental benefits: The current reporting requirements for supplemental benefits like dental and vision care lack detail, making it difficult for beneficiaries to compare plans effectively.
Bipartisan leaders have also raised concerns about the inappropriate marketing practices and impact of prior authorization processes on access to care for MA beneficiaries. Senator Cortez Masto may have said it best, “American taxpayers are paying hundreds of billions of dollars for seniors to use Medicare Advantage plans, but the federal government still doesn't know how much these plans are paying for patient services and how much patients are being forced to pay out-of-pocket.”
