Tens of millions of denials are issued each year for both authorization and reimbursements, and audits of the private insurers show evidence of “widespread and persistent problems related to inappropriate denials of services and payment,” the investigators found.
The report echoes similar findings by the office in 2018 showing that private plans were reversing about three-quarters of their denials on appeal. Hospitals and doctors have long complained about the insurance company tactics, and Congress is considering legislation aimed at addressing some of these concerns.
Under traditional Medicare, there may be an incentive for hospitals and doctors to overtreat patients because they are paid for each service and test performed. But the fixed payment given to private plans provides “the potential incentive for insurers to deny access to services and payment in an attempt to increase their profits,” the report concluded.
Prior authorization, intended to limit very expensive or unproven treatments, has “spread way beyond its original purpose,” Dr. Resneck said. When patients cannot get approval for a new prescription, many do not fill it and never tell the doctor, he added.
from the comments:
I was denied coverage for $13 worth of muscle relaxant pills for excruciating back spasms, and learned this in a text from the pharmacy as I was in pain, about to pick up the prescription. When I called the insurer, I was told I could appeal the denial, which would take 72 hours. It is disgraceful that they expected me to be in agony for three days while they spent far more than $13 on salaries and paperwork to deny me a medicine I needed.
We need a lot more health care and a lot less “health insurance”.
My father was on a Medicare advantage plan in 2020. He became very sick and his liver began to fail. The hospital in NY he was in rejected him for a liver transplant. We had to call and have him accepted to another hospital. When he finally was, his Medicare advantage plan provider rejected the move on the grounds that the same operation/service could be provided at the hospital he was at. Despite having already been rejected there. It took two weeks to appeal their decision. They reversed it. But he passed away before we had the chance to provide him the care he needed.
In 2016, when my otherwise healthy-as-a-horse 81 year old mother had the accident that would change her life, she was released by a CT rehab in two cam boots, unable to bear weight on either foot, with no follow-up plan of care. Why? Because her Medicare Advantage plan’s insurance adjuster, located in a cubicle on the other side of the globe, decided that she didn’t really need to walk, or to have follow up care. I was given 3 days to file an appeal; I did. It was denied, and the “patient advocate” at the rehab called to say Come get your mother.
Why was my mother on a Medicare Advantage Plan to begin with? Because, in 2000, when she was 65 and a recent widow, she received a call from a Medicare Advantage Plan under (then) Oxford, who told her that she “didn’t have to pay a thing–no monthly premium payments, no nothing” and she would be covered for everything. She believed them and signed up.
When my mother had her pre-rehab surgery, her Medicare Advantage Plan refused to pay for her anesthesia; they claimed that “old people feel no pain.” Eventually, I was able to get my mother off her MAP plan, and on to traditional Medicare, with a supplement (that I pay for), but not before incurring hundreds of thousands of dollars of co-pays.
This is no surprise. Medicare Advantage (MA) began life as a GW Bush gift to insurance companies. MA plans, unlike traditional Medicare, spend large sums on marketing with attractive gimmicks such as health club memberships. These memberships select a healthy cohort which is the kind of people MA wants to insure; sick people are less attractive for obvious reasons. It is conceivable that MA plans hope to replace traditional Medicare. Given the likelihood of a Republican landslide in November, I am worried. [[ED–me, too]]
I have a 70s neighbor who takes over a dozen prescription meds…is in poor health, and who is enrolled in (an inexpensive) Medicare Advantage plan (she switched after being brainwashed by the cringeworthy TV ads that appear each fall during open season). She has not seen an actual physician in years, only medical assistants and nurses. …That is because the few participating physicians in our area are booked solid with existing patients. She has to wait months on end to be seen at all by anyone at all and never a physician.
I have original Medicare A/B, with a Part F supplement and Part D drug coverage–ridiculously complicated setup and too confusing to some seniors, such as my neighbor. I can get an appointment very easily with any of numerous doctors.
I pay more than my neighbor pays per month, but in the end she pays more because of lost time, copayments, payment denials, etc.
- As a practicing Pulmonologist, there are few more frustrating things than having to appeal a Medicare Advantage Plan denial for a f/u CT scan of the chest, a study often used to follow pulmonary nodules. Often the appeal is via telephone, and frequently we are speaking with a physician of a different specialty, familiar only with the plan guidelines, not necessarily familiar with my specialty’s standard of care. As an example, I called to appeal one such denial of authorization, and was connected to an Ob-Gyn reviewing the request. When I asked what qualified her to decide about CT scans of the chest, she told me she had an extra certification in vaginal ultrasounds. I was speechless.
In addition, the denial of authorization letter sent to the beneficiary, with a copy to the ordering physician, will state that “your doctor is not following the guidelines” which is a very accusatory and dangerous statement and then clearly inserts the insurer in the middle of the doctor-patient relationship.
One friend was complaining about having a hard time finding doctors who accept Medicare. I told him that was not my experience and asked if he had a Medicare Advantage plan. He said no. I asked to see his membership card. His plan did not use the word “Advantage” in its name, but when I looked it up, yes it was a Medicare Advantage plan. He didn’t even know.
A friend of mine is a nurse who went to work for an insurance company, because she could make far more money stopping health care procedures, then working as a nurse. For every claim she denied - she received a kick back or bonus from her employer. So why would she approve surgeries or medical procedures if she could deny those services and pocket a bonus instead?