WORKWEEK

Some Medicare Advantage health plans have wrongfully denied or delayed prior authorizations and payment requests, according to a new report from the Office of the Inspector General. Are these MA plans genuinely “great” if they only burden patients and providers?

Some Background

The $412 billion MA market is booming. MA plans saw an 8.8% increase in enrollment this year, totaling 28.5 million MA beneficiaries. These plans are growing around 10% per year and the Congressional Budget Office projects the share of MA enrollees will surpass that of Original Medicare beneficiaries by 2030.

MA is attractive to both payers and patients: insurers make a lot of money per patient (over $1,000/patient/month), and beneficiaries get extra health benefits not covered by Original Medicare, like vision, hearing, and dental health.

The Deets

Here’s what the new investigation of 15 of the largest MA organizations found:

• 13% of denied prior authorizations would have been approved under traditional Medicare.
• 18% of denied payment requests would have been approved under traditional Medicare.

Health plans rejected prior authorizations for either not being “medically necessary” or not having sufficient evidence to support a test or treatment. Health plans denied payment requests because of human or system errors (the story of U.S. healthcare)

Profits have likely risen from denying prior authorizations, while problems have increased for providers and patients.

My Thoughts

Prior authorizations suck. No one likes them except for insurance companies.

These above findings show that prior authorizations delay timely access to care, force patients to pay out-of-pocket for denied coverage, and add an unnecessary burden to providers’ already busy workflow. The doctor is meant to practice medicine—not deal with the bureaucracy of insurance companies.

I can’t emphasize this enough—providers should not have to deal with the prior authorization system, especially when it’s not necessarily another provider doing the denying. In one of his satirical videos, Dr. Glaucomfleken describes the prior authorization process for someone not in healthcare:

Doctor: “Well, [the insurance company] wants to make sure I’m ordering something the patient actually needs.”

Non-doctor: “Oh, so you’re talking to another doctor that has your level of expertise?”

Doctor: “No… usually the person didn’t go to medical school.”

Non-doctor: “So they can say the patient CAN’T get a treatment that you, their doctor, recommends?”

Doctor: “yeah…”

Non-doctor: “So these insurance companies are practicing medicine without a medical license.”

Essentially. 

While one of the “pros” of prior authorizations is that they “support” value-based care efforts, I’m sure most providers will say the cons outweigh the pros. So, get rid of this system or rebuild it from the ground up?

Overall, the above findings make me skeptical of MA companies’ tactics. Are they indeed here to provide advantages to their beneficiaries or make as much profit as possible, given the lucrative reimbursement model?