In a strongly worded letter in advance of a Congressional hearing on Medicare Advantage plans, the American Hospital Association urged Congress to increase its oversight over these plans, stating: “strong, decisive, and immediate enforcement action is needed to protect sick and elderly patients, the providers who care for them, and American taxpayers….”

In support of its request, the AHA cited a recent Department of Health and Human Services Office of the Inspector General Report that found that 13% of prior authorization denials and 18% of payment denials actually met Medicare coverage rules and should have been granted.  AHA’s letter listed several “egregious health plan policies” that “remain unchecked,” including:

  • More restrictive internal medical necessary and coverage criteria than in original Medicare
  • Downgrades from inpatient admission to observation status for patients for whom inpatient admission would be considered medically necessary under original Medicare
  • Denials and delays in authorization that restrict eligibility for post-acute care
  • Denials and downgrades in coverage of emergency services after the delivery of care based on outcome rather than what the clinician knew at the time

The AHA asked Congress to take specific action, including passage of The Improving Seniors’ Timely Access to Care Act of 2021, which would streamline prior authorization requirements; establish standardized reporting on health plan performance; conduct more frequent and targeted plan audits; and align original Medicare and Medicare Advantage medical necessity criteria.  The AHA had previously asked the Department of Justice to create a Medicare Advantage Fraud Task Force to conduct False Claims Act investigations into commercial health insurers who routinely deny patients’ access to care and payments to providers.

At the Congressional hearing, Diana DeGette (D-CO), Chair of the Subcommittee on Oversight and Investigations echoed many of the AHA’s concerns.  She likewise cited to the recent OIG Report, including specific cases of a prostate cancer patient who had been denied coverage for routine cancer treatment and a patient with endometrial cancer who was denied a CT-scan.  She stated:

            Our seniors and their doctors should not be required to jump through numerous

hoops to ensure coverage for straightforward and medically necessary procedures.


[S]eniors dealing with serious health issues should not be forced to spend their

precious time and energy fighting needless bureaucracy to receive the care they

are already entitled to.  Unfortunately, too many of them are required to do just that.

Representative DeGette expressed concern not just with Medicare Advantage plan patients’ access to care, but also to the quality of care itself.

The AHA’s list of egregious health plan policies is consistent with the experience of many of Whatley Kallas, LLP’s provider clients. Through these inappropriate denials and reduced payments, Medicare Advantage plans are taking money due to providers to increase their profits. The attorneys at Whatley Kallas, LLP have successfully represented hospitals in challenging these plans’ inappropriate denials and reductions in payments.

The AHA’s letter is linked here and Rep. DeGette’s statement is linked here.  Whatley Kallas’s previous article on the OIG Report is linked here and our previous article on the AHA’s letter to the DOJ is linked here.


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