House Lawmakers Call Out ‘Bad Actors’ Within Medicare Advantage

House lawmakers are pushing for more oversight of Medicare Advantage (MA) plans in light of concerns over higher spending, improper claim denials and access to treatment.

A number of lawmakers on the House Energy and Commerce Committee’s oversight subcommittee examined the issue during a hearing that centered around the MA program on Tuesday.

“I am deeply concerned with recent reports that seniors in private sector Medicare Advantage plans are facing unwarranted barriers to accessing timely, medically necessary care,” Energy and Commerce Chairman Frank Pallone, Jr. (D-N.J.) said during the hearing. “Several studies have raised concerns that insurance companies are denying beneficiaries’ access to treatment and imposing burdensome requirements that delay care. Improper claim denials and increased use of prior authorizations are preventing beneficiaries from receiving the care they need.”


Pallone noted that while many Medicare Advantage plans seemed to be acting responsibly, “bad actors” were endangering the health of seniors and increasing costs for taxpayers.

Though several officials from federal agencies testified, including the U.S. Department of Health and Human Services Office of the Inspector General (HHS-OIG), the Medicare Payment Advisory Commission (MedPAC) and the Government Accountability Office. The U.S. Centers for Medicare & Medicaid Services (CMS) was not represented at the hearing.

“It’s a shame CMS did not agree to testify at this hearing to speak to the work the agency is doing to improve this program,” Rep. Morgan Griffith (R-Va.), a ranking member of the subcommittee, said.


Additionally, no MA plans spoke at the hearing.

During the hearing, Erin Bliss, the assistant HHS inspector general, pointed to OIG findings that plans were using chart reviews or in-home health risk assessments to diagnose patients. Oftentimes, there would be no follow-up.

In total, these diagnoses resulted in an estimated $2.6 billion in risk-adjustment payments for 2017.

Bliss also expressed that plans sometimes delayed or denied beneficiaries’ access to medical care, despite the requested care being medically necessary and meeting Medicare coverage rules.

“In other words, these Medicare Advantage beneficiaries were denied access to needed

services that likely would have been approved if the beneficiary had been enrolled in original

Medicare,” she said. “These denials likely prevented or delayed needed care for beneficiaries.”

Home Health Care vs. Medicare Advantage

In recent years, Medicare Advantage has continued to play a larger role in the Medicare program. Almost 27 million individuals in the U.S. are enrolled in an MA plan.

In the coming years, Medicare Advantage enrollment is expected to hit 50% of the overall Medicare population.

Federal spending for these plans is about $350 billion dollars annually and is expected to

continue to grow as well.

Despite that, home-based care providers have often faced challenges contracting with plans.

Bruce Greenstein, chief strategy and innovation officer at LHC Group Inc. (Nasdaq: LHCG), has pointed out that the rates plans pay for home health care services are not on par with traditional fee-for-service Medicare.

Greenstein was also vocal about how providers are complicit in this dynamic with plans.

“We’re losing,” he said, earlier this year at the Home Care 100 conference. “This is a really serious moment in time for all of us. I’ve been up on these panels and [at] endless conferences talking about the benefits of value-based care and all these cool programs that we’re doing. … But I have to say, we’ve been glossing over this as an industry for far too long. We are getting our clocks cleaned, and we just tend not to talk about it.”

Similarly, Encompass Health Corporation (NYSE: EHC) said that Medicare Advantage rates are at a 40% “discount” compared to fee-for-service Medicare.

Aside from the low rate, John Kunysz — CEO of Intrepid USA — stressed that there were other issues for home-based care providers working in the Medicare Advantage space.

“It’s been a challenge because, not only is the rate lower, but the processing of the claims is 6 to 8 times harder for your back office revenue cycle,” he previously told Home Health Care News. “They just put in so many hurdles.”

At the time, Kunysz called for government intervention.

“The government’s going to have to help in this arena,” Kunysz said. “They’re going to have to start going in, making and streamlining some standards, based upon your primary diagnosis and what you’re referred for.”

Pallone suggested that the subcommittee’s investigation would be ongoing, so it’s likely there will be future hearings.

Ultimately, many of the lawmakers believe, at its best, MA can be a positive resource for seniors.

“The Medicare Advantage program is an important tool for seniors, and we all want to see it succeed,” Diana DeGette (D-Colo.), the subcommittee chairwoman, said during the hearing.

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