The Washington Post has published an article headlined “Hospitals and Doctors are Fed Up with Medicare Advantage,” which reports on increasing provider complaints with Medicare Advantage plans’ claim denials and onerous preapproval requirements. The article quotes Chip Kahn, the president and CEO of the Federation of American Hospitals as saying:  “The insurance companies running the Medicare Advantage plans are pushing physicians and hospitals to the edge.”

As a result of these frustrations, hospitals and physicians have been terminating their participation in Medicare Advantage plans. The article cited the case of Baptist Health in Louisville, which has threatened to terminate its participation with UnitedHealthcare’s and WellCare Health Plans, Inc.’s Medicare Advantage plans.  Baptist Health’s medical group has already terminated its participation in Humana’s plan. In a letter to patients, Baptist Health stated that the Medicare Advantage plans “routinely deny or delay approval or payment for medical care recommended by your physician.”

The article also mentioned an HHS Office of the Inspector General audit of Medicare Advantage plans’ denials of preauthorization requests, which found that 13% of the denied requests should have been approved under Medicare guidelines.

In an effort to address these issues, the Centers for Medicare and Medicaid Services (CMS) adopted rules effective January 1, 2024 that, inter alia, clarify that Medicare Advantage plans must comply with original Medicare’s coverage guidelines and must make medical necessity determinations based on original Medicare’s coverage and benefit criteria.  In a letter to CMS mentioned in the article, the American Hospital Association (AHA) expressed concern that the plans are already adopting policies that violate the new rules and has asked CMS to “conduct rigorous oversight to monitor compliance….”  The AHA letter stated that unless the rules are enforced, the result will be a continuation of “inappropriate denials of medically necessary care and disparities in coverage between beneficiaries in MA and those in the Traditional Medicare program.” (emphasis in the original)

The reporting in the article and the concerns expressed by the AHA letter are consistent with the experience of Whatley Kallas, LLP’s hospital and physician clients. As a result, Whatley Kallas has had to take legal action to compel the Medicare Advantage plans to pay claims for medically necessary care that would have been paid by original Medicare.

The Washington Post article is linked here and the AHA letter is linked here. Whatley Kallas’s previous article on the HHS OIG audit is linked here and our previous article on the new Medicare Advantage rules is linked here.

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